Medication safety is a topic of conversation in every hospital across the country. And where should we be concerned more than in the NICU where our patients cannot advocate for themselves and distractions abound? Several ideas have been touted as beneficial to increase medication safety. Here are just a couple and how they have been implemented or may be improvements in progress.
Uninterrupted time to prepare medications: This is often a challenge in the NICU as medications are often prepared in the midst of a busy patient care area. Alarms are going off that the nurse is also expected to respond to while preparing his/her gentamicin dose, or additional orders are given on admission while the nurse is preparing the Dopamine drip, the nurse is called to speak to a parent on the phone in the midst of preparing a medication and other examples we can all think of. Some hospitals have reported using a “vest” or other mark that the nurse wears to signal that she/he is preparing medications and should not be disturbed. Others have a sign that is placed on the door of the medication room asking that the nurse not be disturbed during medication preparation. However this may be accomplished, the undisturbed time allows the nurse to focus on what they are doing at that moment and ensure the correct medication is given at the correct time, to the correct patient for the correct reason and at the correct dosage.
Standard concentrations: This has been a topic of discussion for some time in the neonatal arena. Some of you will remember the now forbidden “rule of 6” that was used for years to calculate the proper concentration of a continuous infusion such as Dopamine, Dobutamine and others for each patient. This resulted in variable concentrations of the medication that then would infuse at a given rate for a specific dosage. For instance, to deliver Dopamine at 10 mcg/kg/min, the concentration is calculated so that the rate of 1 ml/hr results in that delivery to the patient. This made titration of the medication very easy before the advent of pump libraries but the complexity of the calculations to determine the concentration could result in errors. Many hospitals now have standard concentrations that are used and “smart pump” libraries that make dosing of these medications simple for any weight patient. Some problems have been identified with the variability of “standard” concentrations. Each hospital now creates and utilizes the concentration that the team feels works best for them. This creates problems when infants are transferred from one hospital to another and the concentrations may be different between facilities. Also, the desired concentration may not be commercially available, resulting in a need to further dilute the medication. Therefore, the Institute of Safe Medication Practices (ISMP) has published a list of concentrations that was created by a group from ISMP as well as the Vermont Oxford Network which includes front-line neonatal practitioners. This list is available at www.ismo.org/tools/pediatricconcentrations.pdf . Its purpose is to create a list that is practical for all neonatal units, thus reducing risk upon transport, generate the demand necessary for these preparations to become commercially available, if not already and to standardize pump drug libraries. In short, the point is that we don’t all need to re-create the wheel! This list also includes many other common drugs used in the NICU that are not continuous infusion drugs.
Some other ideas around medication safety will be posted next month. If you have an innovative idea for medication safety that has been implemented and proven to be successful, please send your idea to firstname.lastname@example.org. We’d love to hear your success stories and, with your permission will share those ideas with other readers.