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When staff speaks up for safety we all benefit

A leaky chemotherapy infusion bag and a partially used vial of bupivacaine were caught and reported.

Medication safety is paramount at Asante, which is why the system created the Asante Medication Administration and Safety Committee. In a recent committee newsletter, pharmacy resident Dillon Thai reported on two incidents that show the value of “speaking up for safety.”

Case One

Situation: Oncology nursing staff placed an RER due to discovery of minor leaking of chemotherapy following completion of an infusion.

Background: A doxorubicin, etoposide and vincristine combination chemotherapy infusion was prepared and administered to the patient. After taking the bag down from the patient it was placed into a chemotherapy bag. Nursing noted at that time the bag showed some minor leakage into the chemo bag. Though the leakage was minor and did not cause a safety issue the staff still logged an RER appropriately for follow-up.

Assessment: Nursing captured photographs in the moment of the completed bag. Based on pharmacy review it was noted that the cap appeared to be missing and the line clamp was likely placed too close to the plastic portion at the end of the line resulting in it not sealing completely. This caused some small leakage.

Recommendation: The product was taken back and reviewed, which allowed for training opportunities to be identified. These opportunities were distributed to applicable staff to prevent future events.

Safety story: Speaking up for safety is always important. Even if an event seems minor (as noted above, the leak was after completion of infusion and solely a small quantity within the chemotherapy transport bag). This allows pertinent staff to review the event and provide a good reminder of why our processes and workflows are important and keep our patients safe. This will likely prevent a future safety event.

Case Two

Situation: Labor and Delivery nursing staff discovered a used vial of bupivacaine in the Omnicell accessible stock.

Background: Vials of medications in the Omnicell are intended to be used on a single patient then discarded. Alert nursing and anesthesia staff noted on removal that a vial of bupivacaine was previously used and avoided using it on the new patient. Unused medications can be placed in the return bin and are returned to pharmacy. These items are then visually reviewed and returned to stock. Nursing staff had saved the product for review and follow-up.

Assessment: It was determined that the vial was likely inappropriately returned to the Omnicell return bin due to its appearance. The cap was set in such a way that it appeared to be unused. This was a good catch and easy to have missed.

Recommendation: The Labor and Delivery nursing manager followed up directly with her staff and provided education regarding this event with specifics on product inspection and return bin use. Pharmacy leadership followed up with pharmacy staff to improve our inspection of returned products and to reiterate the importance of this process.

Safety story: Nursing speaking up for safety in this case allowed for education to be disseminated to involved parties. Reporting of this event will help prevent future errors around the handling of used medications and in turn very likely prevent a patient safety event. Use of event reporting allows for prompt and real-time follow up on events like this.

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