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Blinman T, Hiller D. ENFit does not connect as a safety design: Response to Troubleshooting pediatric gastrostomy - ENFit inaccuracies. Nutr Clin Pract 2024; 39:258-260. [PMID: 37933416 DOI: 10.1002/ncp.11090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 10/05/2023] [Accepted: 10/08/2023] [Indexed: 11/08/2023] Open
Affiliation(s)
- Thane Blinman
- Department of Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Dennis Hiller
- Department of Nursing, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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2
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Mazzella D. Reducing Tubing and Device Misconnections. Am J Nurs 2023; 123:43-46. [PMID: 37498038 DOI: 10.1097/01.naj.0000947468.89142.03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
PURPOSE The aim of this quality improvement (QI) project was to explore prevention strategies to reduce tubing and device misconnections that cause patient harm and death. Practicing evidence-based techniques can improve rates of nursing-sensitive indicators, such as central line-associated bloodstream infections, and increase patient safety. METHODS Our nursing quality management team reviewed internal quality data and found 11 reported misconnections. A literature review was performed to identify recommended prevention strategies that have been used to improve patient outcomes. Recommended strategies included promoting environmental safety, providing adequate education to clinicians on adverse events, performing line tracing and line reconciliation, and reporting all errors in real time.The nursing quality management team provided education on recommended best practices to prevent misconnection to various stakeholders. Nursing policies and standards of care were revised to include the practice of line tracing and line reconciliation during handoff, admission, transfers, and clinical tests and procedures. RESULTS The nursing quality management team gathered postimplementation data on education and policy changes. Two incidents of misconnection occurred within four months. In their reports, clinicians adopted the language of line tracing and line reconciliation when describing the events and actions performed. CONCLUSION Implementation of prevention strategies, including adequate education, enabled staff to identify the risk of misconnections and potential adverse events. Clinical staff incorporated line tracing and reconciliation into their practice, improving patient outcomes.
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Affiliation(s)
- Dana Mazzella
- Dana Mazzella is a clinical nurse IV at Memorial Sloan Kettering Cancer Center in New York City. Contact author: . The author has disclosed no potential conflicts of interest, financial or otherwise
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3
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Dias CS, Ferreira CI, Torres RV, Cruz JL. Inadvertent Epidural and Intravenous Line Swap: A Case Report. Cureus 2023; 15:e36698. [PMID: 37113356 PMCID: PMC10128094 DOI: 10.7759/cureus.36698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2023] [Indexed: 03/29/2023] Open
Abstract
Administration of medication via the wrong administration route has the potential for serious morbidity and mortality. Regrettably, because of the ethical implications in such situations, most of our knowledge comes from case reports. This paper reports on the accidental misconnection of intravenous acetaminophen to an epidural line and of the patient-controlled epidural analgesia (PCEA) pump to intravenous access, as a result of patient error. A male patient aged 60-65 years, 80 kg, American Society of Anesthesiologists (ASA) physical status III presented for unilateral total knee arthroplasty under a combined spinal-epidural anaesthesia technique. For postoperative analgesia, a multimodal analgesia regimen including acetaminophen, in combination with a PCEA pump, was selected. During the night, the patient disconnected and reconnected the drug administration lines, resulting in an epidural/intravenous misconnection. After six unsupervised hours, a total of 114 mg of ropivacaine was administered intravenously and the acetaminophen vial, at this time connected to the epidural catheter, was found empty. A full physical examination by the on-call anaesthesiologist showed no abnormal findings and the nursing staff and patient were instructed on signs to look out for and how to monitor for complications. This case highlights the risks associated with intravenous/epidural line misconnection, as well as the impactful variable the patient represents when admitted to a lower vigilance infirmary. This makes it evident that more safety developments are needed to ensure the utmost quality of care is provided to all patients.
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Cavelier M, Gondé H, Costa D, Lamoureux F, Pereira T, Buchbinder N, Varin R, Hervouët C. Development of an Oral Liquid Formulation of Nicardipine Hydrochloride Compounded with Simple Excipients for the Treatment of Pediatric Hypertension. Pharmaceutics 2023; 15:pharmaceutics15020446. [PMID: 36839767 PMCID: PMC9963445 DOI: 10.3390/pharmaceutics15020446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 01/20/2023] [Accepted: 01/27/2023] [Indexed: 01/31/2023] Open
Abstract
Nicardipine hydrochloride is an anti-hypertensive drug that is used off-label to treat hypertension in children. A previous oral formulation of nicardipine hydrochloride was developed using a commercial vehicle as an excipient. However, ready-to-use vehicles are prone to supply shortages, and their composition may undergo substantial modifications. The aim of this study was to propose a new oral formulation of nicardipine hydrochloride 2 mg/mL using simple excipients. The formulation included hydroxypropylmethylcellulose, simple syrup, polysorbate 80, sodium saccharin, citrate buffer, strawberry flavor and 0.2% potassium sorbate. The uniformity of content was maintained before and after agitation. Nicardipine hydrochloride concentration assessed by HPLC-MS/MS remained above 90% for 365 days before opening and for 28 days after opening. pH and osmolality were maintained throughout the study, and no microbial contamination was observed. The uniformity of mass of the delivered doses was evaluated using four different devices. A new oral formulation of nicardipine hydrochloride 2 mg/mL was developed using simple and safe excipients. Pharmacological and clinical parameters remain to be assessed and compared with those of the previous formulation.
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Affiliation(s)
- Marine Cavelier
- CHU Rouen, Department of Pharmacy, F-76000 Rouen, France
- Correspondence:
| | - Henri Gondé
- CHU Rouen, Department of Pharmacy, Normandie University, UNIROUEN, U1234, F-76000 Rouen, France
| | - Damien Costa
- CHU Rouen, Department of Parasitology-Mycology, Normandie University, UNIROUEN, EA7510 ESCAPE, F-76000 Rouen, France
| | | | - Tony Pereira
- CHU Rouen, Department of Pharmacology, F-76000 Rouen, France
| | - Nimrod Buchbinder
- CHU Rouen, Department of Pediatric Oncology and Hematology, F-76000 Rouen, France
| | - Rémi Varin
- CHU Rouen, Department of Pharmacy, Normandie University, UNIROUEN, U1234, F-76000 Rouen, France
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Guha S, Herman A, Antonino M, Silverstein JS, Venkataraman-Rao P, Myers MR. Synthesis of research on ENFit gastrostomy tubes with potential implications for US patients using these devices. Nutr Clin Pract 2022; 37:752-761. [PMID: 35165940 DOI: 10.1002/ncp.10829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Misconnections between enteral devices and other medical devices have been associated with patient death and serious injuries. To minimize such misconnections, the design of connectors on enteral devices has been standardized. The most common adaptation of the standardized enteral connector is called ENFit. Gastrostomy tubes (G-tubes), which may or may not possess the ENFit connector, are increasingly used to deliver commercial and blenderized diets in home settings to enteral device users. To investigate and compare the performance of G-tubes with and without ENFit connectors, research investigations have recently been performed. However, synthesis of such investigations and quantitative discussion of the consequences of transitioning to ENFit-based G-tube devices has not yet occurred. Here we review the research findings from these studies, with data on patient practices from a Mayo Clinic survey, to estimate the impact on tube feeders in home settings of transitioning to ENFit-based G-tube devices. Extrapolating the findings from these studies to US enteral G-tube patients, 2.5%-8.6% of adult patients and 0.2%-1.9% of pediatric patients may experience perceptible slowing in their gravity feeds if using ENFit-based G-tube devices. About 2.5%-8.6% of adult patients and 0.5%-5.5% of pediatric patients (or their caregivers) may need to push with perceptibly more force for syringe push-based feeding using ENFit-based G-tube devices. Lastly, the article offers suggestions for patients and device manufacturers.
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Affiliation(s)
- Suvajyoti Guha
- Office of Science and Engineering Laboratories, Center for Devices and Radiological Health, Silver Spring, Maryland, USA
| | - Alexander Herman
- Office of Science and Engineering Laboratories, Center for Devices and Radiological Health, Silver Spring, Maryland, USA
| | - Mark Antonino
- Office of Product Evaluation and Quality, Center for Devices and Radiological Health, Silver Spring, Maryland, USA
| | - Joshua S Silverstein
- Office of Product Evaluation and Quality, Center for Devices and Radiological Health, Silver Spring, Maryland, USA
| | - Priya Venkataraman-Rao
- Office of Product Evaluation and Quality, Center for Devices and Radiological Health, Silver Spring, Maryland, USA
| | - Matthew R Myers
- Office of Science and Engineering Laboratories, Center for Devices and Radiological Health, Silver Spring, Maryland, USA
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Nair AS, Diwan SM. NRFit connectors in regional anaesthesia- Another step towards safe clinical practice. Indian J Anaesth 2021; 65:701-702. [PMID: 34764507 PMCID: PMC8577707 DOI: 10.4103/ija.ija_551_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 09/08/2021] [Accepted: 09/12/2021] [Indexed: 11/04/2022] Open
Affiliation(s)
- Abhijit S Nair
- Department of Anaesthesiology, Ibra Hospital, Ministry of Health-Oman, Sultanate of Oman
| | - Sandeep M Diwan
- Department of Anaesthesiology, Sancheti Hospital, Pune, Maharashtra, India
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7
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Desideri I, Martinelli C, Ciuti S, Uccello Barretta G, Balzano F. Lopinavir/ritonavir, a new galenic oral formulation from commercial solid form, fine-tuned by nuclear magnetic resonance spectroscopy. Eur J Hosp Pharm 2020; 29:259-263. [PMID: 33214132 PMCID: PMC7677895 DOI: 10.1136/ejhpharm-2020-002389] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 10/28/2020] [Accepted: 11/05/2020] [Indexed: 12/14/2022] Open
Abstract
Objectives The lopinavir/ritonavir combination is one of the first antiretroviral drugs to be used in the treatment of COVID-19. In incapacitated patients, such as those in intensive care, an oral liquid formulation is needed. In Italy a marketed formulation is available, but only by importing it from other European countries. A galenic oral formulation prepared in the hospital pharmacy from lopinavir/ritonavir tablets was fine-tuned, evaluating the content of the active pharmaceutical ingredient (API) and stability of the formulation by using nuclear magnetic resonance (NMR) spectroscopy. Methods To overcome the insolubility of lopinavir/ritonavir in water, ethanol and glycerol have been used as additional excipients. To define the best excipient proportion and best preparation method, three different formulations (ethanol 7.1–7.5%, glycerol 6–15%, and water) and two different preparation procedures (two step vs one step) have been studied. Each formulation has been compared with Kaletra oral solution (lopinavir 80 mg/mL, ritonavir 20 mg/mL) by NMR spectroscopy. API content and stability were measured. Results The presence of ethanol and glycerol as co-solvents is crucial both to improve solubilisation and promote the stability of the oral form. In the two-step preparation method, when crushed tablets were first dispersed in the ethanol/glycerol mixture and then in water, the content of solubilised active ingredients was equal or only slightly lower than the standard Kaletra (range 89–100%). The one-step method provided a comparable API content (65%) to that obtained by using water as the sole dispersing medium. Conclusions The two-step setup method with final 7.1% ethanol and 11% glycerol concentration is an efficient procedure for extemporaneous preparation of lopinavir/ritonavir liquid formulations from crushed tablets. The method combines simplicity of preparation and reconstitution in the hospital ward with good solubilisation, comparable to the commercial solution, and stability of active ingredients over time.
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Affiliation(s)
- Ielizza Desideri
- UO Farmaceutica - Politiche del Farmaco, Pisa University Hospital, Pisa, Italy
| | - Cristina Martinelli
- UO Farmaceutica - Politiche del Farmaco, Pisa University Hospital, Pisa, Italy
| | - Stefania Ciuti
- UO Farmaceutica - Politiche del Farmaco, Pisa University Hospital, Pisa, Italy
| | | | - Federica Balzano
- Chemistry and Industrial Chemistry Department, University of Pisa, Pisa, Italy
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Viscusi ER, Hugo V, Hoerauf K, Southwick FS. Neuraxial and peripheral misconnection events leading to wrong-route medication errors: a comprehensive literature review. Reg Anesth Pain Med 2020; 46:176-181. [PMID: 33144409 PMCID: PMC7841481 DOI: 10.1136/rapm-2020-101836] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 09/24/2020] [Accepted: 09/29/2020] [Indexed: 11/03/2022]
Abstract
We conducted a search of the literature to identify case reports of neuraxial and peripheral nervous system misconnection events leading to wrong-route medication errors. This narrative review covers a 20-year period (1999-2019; English-language publications and abstracts) and included the published medical literature (PubMed and Embase) and public access documents. Seventy-two documents representing 133 case studies and 42 unique drugs were determined relevant. The most commonly reported event involved administering an epidural medication by an intravenous line (29.2% of events); a similar proportion of events (27.7%) involved administering an intravenous medication by an epidural line. Medication intended for intravenous administration, but delivered intrathecally, accounted for 25.4% of events. In the most serious cases, outcomes were directly related to the toxicity of the drug that was unintentionally administered. Patient deaths were reported due to the erroneous administration of chemotherapies (n=16), muscle relaxants (n=4), local anesthetics (n=4), opioids (n=1), and antifibrinolytics (n=1). Severe outcomes, including paraplegia, paraparesis, spinal cord injury, and seizures were reported with the following medications: vincristine, gadolinium, diatrizoate meglumine, doxorubicin, mercurochrome, paracetamol, and potassium chloride. These case reports confirm that misconnection events leading to wrong-route errors can occur and may cause serious injury. This comprehensive characterization of events was conducted to better inform clinicians and policymakers, and to describe an emergent strategy designed to mitigate patient risk.
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Affiliation(s)
- Eugene R Viscusi
- Department of Anesthesiology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Vincent Hugo
- Becton, Dickinson and Company, Franklin Lakes, New Jersey, USA
| | - Klaus Hoerauf
- Becton, Dickinson and Company, Franklin Lakes, New Jersey, USA.,Department of Anesthesiology and Intensive Care Medicine, Medical University of Vienna, Wien, Austria
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Paparella S. Making Ends Meet…When They Shouldn't: Accidental Misconnections Involving Endotracheal and Tracheostomy Cuff Ports. J Emerg Nurs 2020; 46:111-115. [PMID: 31918804 DOI: 10.1016/j.jen.2019.10.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 10/01/2019] [Accepted: 10/06/2019] [Indexed: 11/15/2022]
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10
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Litman RS. Use of a public health law framework to improve medication safety by anesthesia providers. JOURNAL OF PATIENT SAFETY AND RISK MANAGEMENT 2019. [DOI: 10.1177/2516043518825383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Ronald S Litman
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- Institute for Safe Medication Practices, Horsham, Philadelphia, PA, USA
- Department of Anesthesiology and Critical Care, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Abstract
Infusion-associated medication errors have the potential to cause the greatest patient harm. A 21-year review of errors and near-miss reports from a national medication error-reporting program found that infusion-associated medication errors resulted in the identification of numerous best practices that support patient safety. A content analysis revealed that most errors involved improper dosage, mistaken drug choice, knowledge-based mistakes, skill-based slips, and memory lapses. The multifaceted nature of administering medications via infusions was highlighted. Opportunities for improvements include best practices such as developing learning cultures and reinforcing the independent double-check process on medications. Staff will likely benefit from education on specific medications, prescription details, and smart pump technology.
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12
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Tsukamoto T, Miyata M, Hirata N, Hosoi N, Matsumura Y, Akiba T. Modification of the Dialysate Port of Plasma Separators for Safe Blood Purification in Japan. Ther Apher Dial 2019; 23:396-403. [PMID: 30556345 DOI: 10.1111/1744-9987.12785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 12/11/2018] [Accepted: 12/14/2018] [Indexed: 11/30/2022]
Abstract
A fatal mix-up of a hemofilter with a plasma separator occurred in 2011. The close resemblance between the two blood purification columns commonly used in Japan posed a fundamental risk for such mix-ups. Both the in-hospital case investigation committee and the relevant academic societies have independently proposed the modifications of the dialysate port (D port) of the plasma separator to avoid this type of misuse. To make these devices foolproof, medical professionals, including physicians and clinical engineers, and members of the Medical Technology Association of Japan discussed measures to prevent this type of recurrence. Since new standards were soon to be issued by the International Organization for Standardization (ISO), the modifications were temporarily postponed. In September 2016, the ISO released new standards for small-bore connectors. The shape changes of the D port from the current slip-in type (ISO8637) to the Luer lock type (ISO80369-7) had been already approved by the Ministry of Health, Labor and Welfare of Japan by the end of November 2018, including a temporal use of a converter to connect the current type of D port to the new type of blood circuit. We must address the next issue that the new standard and the older standard coexist in the clinical setting, which may create a new risk.
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Affiliation(s)
- Tatsuo Tsukamoto
- Department of Nephrology and Dialysis, Kitano Hospital, Tazuke Kofukai Medical Research Institute, Osaka, Japan.,Department of Nephrology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Makiko Miyata
- Medical Technology Association of Japan, Tokyo, Japan
| | - Noriko Hirata
- Medical Technology Association of Japan, Tokyo, Japan
| | | | - Yumi Matsumura
- Department of Patient Safety, Kyoto University Hospital, Kyoto, Japan
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El-Boghdadly K, Pawa A, Chin KJ. Local anesthetic systemic toxicity: current perspectives. Local Reg Anesth 2018; 11:35-44. [PMID: 30122981 PMCID: PMC6087022 DOI: 10.2147/lra.s154512] [Citation(s) in RCA: 212] [Impact Index Per Article: 35.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Local anesthetic systemic toxicity (LAST) is a life-threatening adverse event that may occur after the administration of local anesthetic drugs through a variety of routes. Increasing use of local anesthetic techniques in various healthcare settings makes contemporary understanding of LAST highly relevant. Recent data have demonstrated that the underlying mechanisms of LAST are multifactorial, with diverse cellular effects in the central nervous system and cardiovascular system. Although neurological presentation is most common, LAST often presents atypically, and one-fifth of the reported cases present with isolated cardiovascular disturbance. There are several risk factors that are associated with the drug used and the administration technique. LAST can be mitigated by targeting the modifiable risk factors, including the use of ultrasound for regional anesthetic techniques and restricting drug dosage. There have been significant developments in our understanding of LAST treatment. Key advances include early administration of lipid emulsion therapy, prompt seizure management, and careful selection of cardiovascular supportive pharmacotherapy. Cognizance of the mechanisms, risk factors, prevention, and therapy of LAST is vital to any practitioner using local anesthetic drugs in their clinical practice.
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Affiliation(s)
- Kariem El-Boghdadly
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK, .,School of Medicine, King's College London, London, UK,
| | - Amit Pawa
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK,
| | - Ki Jinn Chin
- Department of Anesthesia, Toronto Western Hospital, University of Toronto, Ontario, Canada
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