PASA Purchasing for Safety – Injectable Medicines
Derby Hospital’s NHS Foundation Trust Pilot
4. Skills decay. Devices not used
frequently including PCA pumps used
only once per week on one patient.
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Recommendations
Need to confirm from medication incident data
Need to ensure good representation from
labour ward in semi-structured interviews
Gill Ogden to review and provide breakdown of
errors in Maternity areas
Avril Satchwell Fowler to include labour ward
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Knowledge
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Medical
Devices &
Consumables
Injectable
Medicines
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Process
Risk to Staff
Safety
Process
1. It was suggested that labour ward
had the highest incidents of injectable
medication errors as the pre and post
natal ward do not carry out the same
level of usage of pumps, or injectable
medication.
Pumps and consumables
2. Equipment for infusion not always
available. Intervention commenced on
labour ward and treatment transferred
with patient to post natal ward – pump
required back in labour ward.
3. Syntocinon – no pre made available
as no stability. 3 different regimes
required for different aspects of care,
induction, post delivery and during
post partum haemorrhage. During
emergency situation 2 preparations
are required in different quantities.
Risk to Patient
Safety
Issue
Priority
FOCUS GROUP: Maternity Focus Group
Need to review transfer process to ensure
continuity of care; see Trust Transfer policy.
Review access to equipment library for pumps
Mark Cannell to follow up as appropriate
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Currently making up
different solutions
with different
concentrations which
increase the risk of
error or confusion
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This could be one for
a case study
This could be an action for the Trust to
consider the concentration of syntocinon such
that the same bag could be run at different
speed during stages of labour, delivery and
post delivery. This has been looked at in the
past, but warrants review. Action taken to
separate bolus and infusion strengths, but
agree standardisation of concentration.
Lisa Robb to address with Maternity services
Consider trained staff facilitators in each area
to manage infrequent use. Mark Cannell and
Leslie Hancock to review IV training needs
PASA Purchasing for Safety – Injectable Medicines
Derby Hospital’s NHS Foundation Trust Pilot
5. Same device used for IVs infusions
as per epidurals. Alternative pump
available, however maternity staff
believe this pump to takes too long to
set up. Therefore several actions have
been taken to ensure the IV pump for
epidurals is clearly labelled and
identified with different colour giving
set to that used for IVs
6. IV access lines have extension line
attached. These increase the dead
space between the IV and the
infusion. When bolus doses are given
the dead space fluid is also primed
which gives and overdose of the drug.
Medicines
7. Drug cupboard not universally
stored.
8. drugs often in different boxes –
change of manufacturer
9. Hydralazine often cannot be found
in a hurry
10. Boxes to be clearly labelled
detailing routes not to be administered
by.
11. Pre draw syringes at start of shift
12. Phenephedrine made up to
concentration in a bag and then
multiple doses are drawn up for one
patient as required.
13. Infusion checklists are available for
use in the Trust however these were
reported as not being used routinely in
maternity. One reason for this was
thought to be due to not being
commenced in theatre or recovery of
patient.
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This could be part of
a consumables
design case study
Use of extension lines, three way taps, ramps
etc add to complexity of infusion system and
risk of incorrect administration, incompatibility
and confusion.
Project team to review as case study in Trust
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This is obviously and
issue for the Trust as
a whole
As mentioned before
Action plan or case study. This is a significant
risk for theatre / critical care areas in particular
Pilot team to review as case study for Trust
Action plan or case study. As in item 20 in
Theatres / Imaging feedback. Action pharmacy
As above. Consider separate area / kit for
emergency drugs.
Important development ‘flagging’ essential
information (dose, route, prep, admin etc).
Pilot team to review as case study for Trust
Action plan. As in items 2,16 in Theatre plan
As per Theatre feedback item 23. Currently
requires dilution to appropriate concentration
prior to administration of dose. Alternatives
under review.
Action plan. The infusion checklist should be
used throughout the Trust to document checks
and monitor important parameters for safe IV
administration. To monitor incidents via IFSC
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This has been reviewed extensively by Risk
Management. Action taken to minimise risk,
and as part of NPSA Alert 21 Safer Use of
Epidural Injections and Infusions. Any further
action to be undertaken by Action Group.
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This could be part of
a case study
PASA Purchasing for Safety – Injectable Medicines
Derby Hospital’s NHS Foundation Trust Pilot
14. Maternity was shown to have a
higher than average reporting of
needle stick injuries this was reported
as being due to a number of suturing
incidents which occur during
emergency caesarean sections when
doctors do not remover their hands in
time during the procedure.
15 glass ampoule design is leading to
multiple cuts to hands
16. Transfers from other hospitals
occasionally are admitted with pumps
in progress which are not consistent or
cause confusion to Derby Trust staff
due to differences.
17. There was a reported blanket
usage of Clexane for all post C/S
patients which increases the risk of
PPH etc
Knowledge
18. Timeline of training to next use of
equipment
19. Maternity has their own clinical
incident reporting system separate to
the Trust one. This is in part due to the
requirements by CNST
20. High risk drugs often given via a
number of different routes, therefore
single preparation not applicable.
21. Identification of multiple accesses
– good practice would be to tuck the
epidural route which is not used as
frequently under a pillow.
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No further action within this project
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Consider availability of ampoule openers or
plastic alternatives to use of glass ampoules
Trust policy is to transfer patient to DHFT
approved administration equipment on arrival.
May require new infusion to be prepared by
pharmacy.
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This is a quick win for the Trust and should be
part of an action plan. VTE guidelines currently
under review by Trust clinical committees.
Audit use against documented assessment
and clinical guidelines. Action: Directorate
Case study
As in item 15 theatres feedback – decay of
knowledge and competency.
Mandatory requirement. Concern that current
standardised incident reporting form is less
effective for medication errors and analysis of
root causes. Review by Risk Management.
As in item 10, could be included within
essential information flagged to product.
Pilot team to review as part of case study
These need to be clearly labelled / identified.
Agree ‘protecting’ epidural access will reduce
risk. Anaesthetists to agree as standard
practice across Division.
PASA Purchasing for Safety – Injectable Medicines
Derby Hospital’s NHS Foundation Trust Pilot
Completing the Form
Issue
These are the key issues which were identified during the Focus Group session
Priority
If 1 = Highest Priority, and 5 = Least Priority. Please indicate your preferred “top five” issues from the list above.
Risk to Patient
Safety
Please indicate on a scale of 1 to 5 (where 1 = no risk, and 5 = severe risk) your perceived risk to patient safety of this
issue
Risk to Staff Safety
Please indicate on a scale of 1 to 5 (where 1 = no risk, and 5 = severe risk) your perceived risk to staff safety of this
issue
Medical Devices
& Consumables
Place a tick in the box if the issue relates to Medical Devices, Equipment and/or their consumables
Injectable
Medicines
Place a tick in the box if the issue relates to injectable medicines
Knowledge
Place a tick in the box if the issue relates to a specific training or knowledge gap
(ticks can be placed in more than 1 box)
(ticks can be placed in more than 1 box)
(ticks can be placed in more than 1 box)
Recommendations
If you have a specific recommendation or request as to how an issue might be resolved or improved please provide
information.
(this is particularly relevant if you believe purchasing for safety might play an important part in improving the current
situation)
Completed by :-
81902241
NAME :
Tom Gray
DESIGNATION :
Chief Pharmacist, Derby Project Lead
BLEEP / EXT :
85562