Medication Safety Practices in Perianesthesia Care Jennifer Watson, PharmD Medication Safety Pharmacist Centracare – St. Cloud Hospital

Objectives 1. Discuss safe medication administration practices in the perioperative setting. 2. Review strategies to improve patient safety with regard to high risk or more error prone medication practices.

CDC guidelines for safe injection practices 1. Use of single dose vials, when available, over MDV a. Use of single dose vials preferable b. Only vials labeled for multiple dose can can be used more than once c. Beyond use dating (BUD) on multiple dose vials only – 28 days unless otherwise specified

2. Adherence to aseptic technique a. Cleaning septum with 70% alcohol b. Proper hand washing techniques 3. Use of 1 needle/1 syringe per patient

In recent news, there were cases of insulin pens being used on multiple patients. Where the needle connects to the pen, there is a hub. It was found that regurgitation could occur, possibly causing blood/tissue to go into the hub.

Incremental/range dosing 1. Frequency needs to be based on pharmacokinetics of the medication 2. The range should not exceed twice that of the lowest dose 3. Initiate at lowest dose of the range 4. Monitor patient for clinical response and vital signs

Labeling requirements 1. Must occur anytime a medication is removed from the original container to another 2. Must occur prior to the transfer from original container 3. Original container must be kept as a reference 4. Label must list drug name, strength, quantity, diluent and volume

Pediatric dosing for pain – weight based 1. Ibuprofen and Acetaminophen are first line a. Ibuprofen 4-10mg/kg/dose q6-8h prn (max of 40mg/kg/day) b. Acetaminophen: <2 yo: mg/kg/dose q6h prn (max of 60mg/kg/day) 2-12 yo: mg/kg q6h prn (not to exceed 3750mg/day)

2. Morphine is second line a. Oral mg/kg/dose q4-6h prn b. IV – mg/kg/dose q2-4h prn 1-6 yo: max of 4mg/dose 7-12 yo: max of 8mg/dose

3. Acetaminophen and Codeine - for many years considered the go-to medication for pain in children - no longer recommended because of rapid metabolizers 4. Tramadol - use in the Pediatric population (under the age of 16) has not been established

Pediatric dosing of antiemetics - Zofran® (ondansetron): used primarily for post-operative nausea in children - available in liquid, sublingual tablet and IV - dosing recommendations: 1 month-12yo, <40kg: 0.1mg/kg/dose IV 1 month-12yo, >40kg: 4mg IV

6 AORN Medication Safety Concepts 1. Storage – intermingling same medications but different sizes/strengths in same compartment 2. Preparation – making the medication as close to the time of use as possible 3. Labeling 4. Verification – do not rely on the cap color or vial shape

5. Disposal – ensure that proper disposal containers are available 6. Sharps Safety – utilize needleless systems

High Risk Medications 1. Opioid infusions (PCA, epidurals) a. No basal infusion rates for opioid naïve patients b. Opioid naïve patients use bolus dosing only 2. IV push opioids a. Initiate at the lowest dose (if range order)

3. Sedation agents a. Midazolam – FDA indicated for sedation not an anxiolytic b. Lorazepam – used in sedation and anxiety - Has a half life of 12-14hrs 4. Promethazine – because of possible tissue necrosis, we have limited it to IV piggyback through a central line

NCPS Patient Safety Intervention Hierarchy 1. Weaker actions (all reliant upon memory and vigilance) a. Double checks b. Warnings and labels c. New procedure/memo’s/policy d. Training/education e. Additional study/analysis

2.Intermediate actions a. Redundancy b. Increase in staffing/decreasing workload c. Software changes d. Checklists e. Read back

3. Stronger actions (focused on system change and not relying on memory). a. Physical changes to environment b. Forcing functions c. Simplifying the process d. Must have involvement of leadership

Medication Safety Strategies 1. Order Sets a. Opioid naïve vs. opioid tolerant b. Reviewing ranges and frequencies for appropriateness c. Order sets specific to pediatrics 2. Utilizing bar code scanning – 5 rights 3. Independent double checks 4. Limit vial strength/size

5. Utilizing automatic medication dispensing cabinets 6. Document dose prior to administration of medication 7. Utilizing smart pumps 8. Tracing back the lines 9. Patient monitoring – pulse oximetry, respiratory rate, capnography 10.Utilizing your pharmacist

References: Barbara Milani, Nicola Magrini, Andy Gray, Phil Wiffen and Willem Scholten. WHO Calls for Targeted Research on the Pharmacological Treatment of Persisting Pain in children with Medical Illnesses. Evid.-Based Child Health; 6: (2011). Centers for Medicare and Medicaid Services (2014, March 14). Memorandum: Requirements for Hospital Medication Administration, Particularly Intravenous (IV) Medications and Post-Operative Care of Patients Receiving IV Opioids. [On- Line]. Available: Guidance/index.html Guidance/index.html

The Joint Commission E-dition release 6.0. (2014, January 1). Medication Management Standards (MM). [On-Line]. Available: Association of periOperative Registered Nurses (2013, May 1). 6 Key Medication Safety Concepts. [On-Line]. Available: Institute for Safe Medication Practices. (2014). ISMP’s List of High-Alert Medications. Retrieved September 1, 2014, from