Infection control
Needlestick injury
Medication errors & drug incompatibility
Exposure to blood and drugs
Air embolism, disconnections and misconnections
Anesthesia Safety
Medication errors and Drug Incompatibility
A medication error is defined as any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer.
According to a review published in ‘Drug Safety’ magazine in 2007 medication errors occurred in a mean of 5.7% of all episodes of drug administration.
Unintentional administration of anesthetic agents have recently gained awareness for being recognized as a drug error following incidents of residual anesthesia drugs in intravenous lines that caused respiratory arrest followed by cardiac arrest, shortly after the intravenous line was flushed.
Drug Incompatibility is another variation of medication error that refers to an undesirable reaction that occurs between a drug and a solution, container or another drug. Although critically ill patients usually have various central intravenous (i.v.) lines, numerous drugs have to be infused simultaneously through the same lines. This can result in potentially harmful in-line incompatibility that can cause decreased drug effectiveness or increased microparticle load.
Physicochemical incompatibilities of intravenous solutions are major concerns because they may impair the efficacy of the drug or increase the risk for adverse effects. Drug incompatibilities are frequent, accounting for 20% of all medication errors and up to 89% of administration errors. They emerge as color change, clouding, gas formation, turbidity, and precipitation or may lead to invisible chemical reactions, such as pH changes, or complex reactions, which can result in formation of irritating or toxic compounds or reduced bioavailability of the active ingredient.
Meeting the Challenge
Elcam’s MarvelousTM stopcock benefits are aimed at increasing patient safety relative to medication errors and drug incompatibility. The Marvelous features a unique circumferential channel that reaches the entire internal volume of the valve. Constant flushing of the side port with (main line) carrier fluid minimizes dead space and assures complete rinsing of the drug from the system thereby reducing the chance of drug interactions and unintentional administration of residual drugs. Furthermore, by decreasing the number of stopcock manipulations with the reduction of pre-medication flushing with a syringe, the Marvelous contributes to decreasing the chances of medication errors.
Related Articles
- FDA : Medication Errors
- Drug-related problems in hospitals: a review of the recent literature. *Krähenbühl-Melcher A1, Schlienger R, Lampert M, Haschke M, Drewe J, Krähenbühl S.Drug Safety. 2007;30(5):379-407.*
- Residual anaesthesia drugs in intravenous lines – a silent threat? *S. Bowman ST6 Anaesthesia, K. Raghavan Consultant Paediatric Anaesthetist, and I. A. Walker Consultant Anaesthetist, Honorary Senior Lecturer. Anaesthesia: Volume 68, Issue 6, pages 557–561, June 2013*
- AJHP: Standardization of infusion solutions to reduce the risk of incompatibility; *Karin Nemec, Hannelore Kopelent-Frank and Robert Greif.*
- Prevention of Intravenous Drug Incompatibilities in an Intensive Care Unit; *T Bertsche, Y Mayer, R Stahl, T Hoppe-Tichy, J Encke, W Emil Haefeli; Am J Health Syst Pharm. 2008;65(19):1834-1840.*