Heparin update New Zealand

Stewart Jessamine, Group Manager, Medsafe in conjunction with the Ministry of Health (NZ)  are continuing to monitor the situation with respect to the global problem of heparin contaminated with over-sulphated chondroitin sulphate (OSCS) entering the market.

Medicines regulators around the world have taken a number of different approaches to managing this issue.  In New Zealand, Medsafe requires all manufacturers of heparin-based products to test for the presence of OSCS in products supplied to the market. To date all of the manufacturers of heparin and low molecular weight heparin products supplied to New Zealand have reported that OSCS has not been detected in the products used by patients.

Click here for the full update.

Barcode medication system

Actor Dennis Quaid, whose twins were given an overdose of a blood thinner as newborns at a California hospital, toured a Dallas hospital on Tuesday to learn about a system to prevent such errors.

Officials at Children’s Medical Center Dallas showed Quaid and his wife, Kimberly, the hospital’s system of bar-coding medications to allow the drugs to be tracked electronically from the point of dispensing until being administered to the patient.

“This system here at Children’s Medical Center, I’m really amazed … it’s beyond cutting edge,” Quaid said at a news conference after the tour.

Click here to view the full story.

 

MedPro and Greiner

MedPro Safety Products, has entered into two medical supply manufacturing agreements with Greiner Bio- Read more

Epidural and IV confusion

In 2006 Jasmine Gant, 16, died following a mistake by nurse Julie Thao. Jasmine died following an inadvertent disconnection of her epidural during childbirth. Thao mistakenly attached the epidural to the IV device.

The Wisconsin State Journal state that progress has been made to increase the safety associated with tubing connections, but obstacles continue.

“It’s inching along,” said Rod Hicks, a professor at Texas Tech University and former research manager at U.S. Pharmacopeia, a nonprofit organization that sets standards for the drug industry. “But these errors can still occur. We have not made the world a safer place yet.”

This article calls for industry to provide the solution to safer tubing connections in healthcare.

Click here to read the full story.

Revised EU monographs for heparin

The MHRA have reported a revision of European Pharmacopoeia monographs for heparin.

“Following increased reports of adverse events associated with heparin preparations in the United States of America and some European countries, the European Pharmacopoeia monographs for Heparin Calcium (0332) and Heparin Sodium (0333) have undergone rapid revision and implementation in order to strengthen the level of testing required for quality control.

The revised monographs were adopted by the European Pharmacopoeia Commission on 25 June 2008 and are expected to come into effect on 1 August 2008, pending a decision by the European Committee on Pharmaceuticals and Pharmaceutical Care (CD-P-PH).

The revised monographs will be published in European Pharmacopoeia Supplement 6.4 and supersede the relevant monographs published in the British Pharmacopoeia 2008 and 2009 editions.

Further information and copies of the monographs can be obtained from the EDQM (European Directorate for Quality of Medicines & HealthCare) website“.

ASHP’s IV Safety Summit

ASHP and its partners will gather healthcare practitioners, thought leaders and medication-safety experts from around the nation to achieve consensus on actions that bring about real and lasting improvements in the use of IV medications, protecting patients from harm and death due to errors.

Summit Goals

• Achieve consensus on an initial set of broadly applicable standard practices and methods that are effective in preventing patient harm or death associated with the use of intravenous medications.
• Identify barriers to adoption or implementation of the practices and recommend specific actions to overcome them. Practices will be prioritized into an essential core group for immediate implementation and those requiring a phased-in approach.
• Identify areas for future research and issues that are specific to and should be resolved by various stakeholder groups.

The summit will take place on July 14 & 15, Rockville, Maryland. The organizers request that you check the ASHP website for summary materials and updates.

 

Wireless may disrupt IV devices

It have recently been reported that Wireless systems used by many hospitals to keep track of medical equipment can cause potentially deadly breakdowns in lifesaving devices such as electronic infusion devices.

Some of the microchip-based “smart” systems are touted as improving patient safety, but a Dutch study of equipment — without the patients — suggests the systems could actually cause harm.

The wireless systems send out radio waves that can interfere with equipment such as respirators, external pacemakers and kidney dialysis machines, according to the study.

Researchers discovered the problem in 123 tests they performed in an intensive-care unit at an Amsterdam hospital. Patients were not using the equipment at the time. Nearly 20 percent of the cases involved hazardous malfunctions that would probably harm patients. These included breathing machines that switched off; mechanical syringe pumps that stopped delivering medication; and external pacemakers, which regulate the heart, that malfunctioned.

Click here to read the full story.

Click here for the story again - different report.

UPDATE - Another news item - Wireless Hospital Tracking System Study Needlessly Alarms Public.

Barcode patient

The nurse scans the wristband barcode to make sure it matched information on his medication and on her computer screen.

Wayne Memorial’s new Bedside Medication Verification (BMV) program officially launched this month. BMV supports the “Five Rights” of Medication Management: Right Patient, Right Medication, Right Dosage, Right Route, and Right Time. Caregivers scan the patient’s wristband barcode and then scan the code on the medication to be administered to correctly identify that the right medication at the right dose is being given to the right patient at the right time and by the right route (intravenous, oral, etc). 

 “This is a real milestone for Wayne Memorial,” said David Hoff, Chief Executive Officer. “BMV is one of the most important steps we’ve ever taken for patient safety.”    

Click here for more on this story

 

Medication safety and job satisfaction

Medication safety, nursing, job satisfaction and management go hand-in-hand.

Bowcutt M., Rosenkoetter M.M., Chernecky C.C., Wall J., Wynn D. and Serrano C (2008) Implementation of an intravenous medication infusion pump system: implications for nursing. Journal of Nursing Management. 16(20, p.188-97.

Abstract:

“To assess perceptions of nurses regarding the implementation of intravenous medication infusion system technology and its impact on nursing care, reporting of medication errors and job satisfaction. Medication errors are placing patients at high risk and creating an economic burden for hospitals and health care providers. Infusion pumps are available to decrease errors and promote safety. Survey of 1056 nurses in a tertiary care Magnet hospital, using the Infusion System Perception Scale. Response rate was 65.43%. Nurses perceived the system would enhance their ability to provide quality nursing care, reduce medication errors. Job satisfaction was related to higher ratings of the management team and nursing staff. Perceptions verified the pump was designed to promote safe nursing practices. It is important to consider relationships with job satisfaction, safe nursing practice and the importance of ratings of nursing staff and management teams when implementing infusion technology. Infusion pumps are perceived by nurses to enhance safe nursing practice. Results stress the importance of management teams in sociotechnological transformations and their impact on job satisfaction among nurses” (Bowcutt et al 2008).

 

Impressive fall in needlestick injuries

These authors have demonstrated  an impressive fall in needlestick injuries with minimal cost outlay.

Whitby M., McLaws M.L. and Slater K (2008) Needlestick injuries in a major teaching hospital: the worthwhile effect of hospital-wide replacement of conventional hollow-bore needles. American Journal of Infection Control. 36(3), p.180-6.

Abstract:

“Needlestick injury (NSI) with hollow-bore needles remains a significant risk of bloodborne virus acquisition in health care workers. The impact on NSI rates after substantial replacement of conventional hollow-bore needles with the simultaneous introduction of safety-engineered devices (SEDs) including retractable syringes, needle-free intravenous (IV) systems, and safety winged butterfly needles was examined in an 800-bed Australian university hospital. NSIs were prospectively monitored for 2 years (2005-2006) after the introduction of SEDs and compared with prospectively collected preintervention NSI data (2000-2004). Preintervention hollow-bore NSI rates over 10 years persisted at a constant rate between 3.01 and 3.77 per 100 full-time equivalent employees (FTE) (P = .31). Rates for 2005 (1.93; 95% CI: 1.48-2.47 per 100 FTE) and 2006 (1.50; 95% CI: 1.11-1.97 per 100 FTE) were significantly lower than the average rate for the preintervention years (3.39; 95% CI: 2.7-4.24 per 100 FTE, P = .00004). This represents a fall of 49% (43.1%-55.7%) in hollow-bore NSI, contributed to by the virtual elimination of NSI related to accessing IV lines. More importantly, high-risk injuries were also reduced 57% by retractable syringe use with an overall budgetary increase of approximately US $90,000 per annum. Introduction of SEDs results in an impressive fall in NSI with minimal cost outlay” (Whitby et al 2008).

HepC contamination - CDC full report

The Morbitity and Mortality Weekly Report (MMWR) from the CDC into “Acute Hepatitis C Virus Infections Attributed to Unsafe Injection Practices at an Endoscopy Clinic, Nevada, 2007″ has been published. The report is very thorough, it describes the investigation and highlights how the contamination may have occurred. Click here for the full report.

The CDC write “On January 2, 2008, the Nevada State Health Division (NSHD) contacted CDC concerning surveillance reports received by the Southern Nevada Health District (SNHD) regarding two persons recently diagnosed with acute hepatitis C. A third person with acute hepatitis C was reported the following day. This raised concerns about an outbreak because SNHD typically confirms four or fewer cases of acute hepatitis C per year. Initial inquiries found that all three persons with acute hepatitis C underwent procedures at the same endoscopy clinic (clinic A) within 35–90 days of illness onset. A joint investigation by SNHD, NSHD, and CDC was initiated on January 9, 2008. The epidemiologic and laboratory investigation revealed that hepatitis C virus (HCV) transmission likely resulted from reuse of syringes on individual patients and use of single-use medication vials on multiple patients at the clinic. Health officials advised clinic A to stop unsafe injection practices immediately, and approximately 40,000 patients of the clinic were notified about their potential risk for exposure to HCV and other bloodborne pathogens. This report focuses on the six cases of acute hepatitis C identified during the initial investigation, which is ongoing; additional cases of acute hepatitis C associated with exposures at clinic A might be identified. Comprehensive measures involving viral hepatitis surveillance, health-care provider education, public awareness, professional oversight, licensing, and improvements in medical devices can help detect and prevent transmission of HCV and other bloodborne pathogens in health-care settings”.

Click here for the full report.

Photosensitivity with Cipro

Medscape has recently reported that “The US Food and Drug Administration (FDA) has approved safety labeling revisions to advise of the risks for photosensitivity and phototoxicity in patients receiving treatment with quinolone antibiotics such as ciprofloxacin, updated information regarding the risk for cardiomyopathy in patients receiving trastuzumab therapy, and the potential for developing Clostridium difficile–associated diarrhea more than 2 months after completion of antimicrobial therapy”.

CME credits are available for this subject through the Medscape website.

Improving patient safety

Simon Keady and Meera Thacker offer an insight into the rationale and steps being taken in response to recent NPSA alerts.

Reference

Keady S. and Thacker M. (2008) National Patient Safety Agency: Improving patient safety across all critical care areas. Intensive and Critical Care Nursing. 24, p.137-140.

“The National Patient Safety Agency (NPSA) reviews patient safety incidents throughout the National Health Service (NHS) in the United Kingdom and aims to initiate preventative measures. Recent alerts include injectable medication, oral syringes for enteral administration, preventing hyponatraemia in children and anticoagulation. This article gives an insight into the rationale and steps currently being undertaken to respond to these recommendations” (Keady and Thacker 2008).

COSMOS study launched

The Hospital San Carlos, Madrid, Spain has started to recruit patients into a randomized study of closed peripheral intravenous systems versus open systems. The research team have named it the COSMOS Study (great name… lets hope the results are out of this world).

The purpose of this study is to investigate, in a prospective and randomized fashion, the clinical performance of a closed intravenous system (Nexiva®) versus an open conventional one (Vasocan®), with respect to ease of handling and effectiveness (as defined by time of survival without complications), security provided to professionals and patients against accidental blood exposure or needlestick injury, catheter-related complications such as phlebitis, pain and blockage and overall costs of the two systems.

Primary Outcome Measures:

Length of time catheter remains in place without clinical symptoms.

Secondary Outcome Measures:

Incidence of complications of the catheter, bacterial colonization of catheter tips and costs of therapy.

The study is due to complete July 2008. Click here for further information.

IV safety articles

Just found this excellent range of articles that examine the issue of sharps injury. Topics include current trends and future opportunities associated with percutaneous needlestick injury and a focus upon needlestick injury prevention. Click here to view the article.

Needlefree alert

The MHRA have issued an alert that describes how the septum of a needleefree device may remain recessed. Click here to view the alert.

BARD buy safety needle

The IV device market continues to  consolidate as BARD pay $68 million for Specialized Health Products International Inc… the company primarily make safety needles for the intravenous chemotherapy market.

“The deal represents a good fit, in our view, and should be neutral to earnings in 2008,” said Lehman Brothers analyst Bob Hopkins, in a note to investors.Click here for the full story. 

European needlestick legislation on the cards

The European Union is consulting on legislation to ensure healthcare workers have more safeguards against the potential for needlestick injuries. It is suggested that the proposed legislation will include  Read more

UK nurse died following needlestick

A sad and thankfully rare incident. This nurse received a needlestick injury and developed HIV after testing the blood sugar levels of a HIV positive patient “The hospital room Read more

Baxter receives clearance from FDA for ’silver’ needlefree

Baxter receive clearance from the FDA for a silver coated needlefree device. The V-Link luer activated device is coated on the outside and the inside with Vitalsheild silver protective coating. This is said to be the first in a series of new products from Baxter. To view this news item in full click here.

Intervene distribute Surety safety needle

Intervene has begun to distribute the Surety safety needle. The Surety needle is the World’s first manually retractable, hypodermic safety needle that can be used with standard slip luer and luer lock syringes. For further information check out the Intervene website.

MHRA alert MDA/2007/089

The MHRA have recently published an alert to warn practitioners of the risk of back tracking when more than one IV line is connected through a single access point. I would hope when practitioners setup the IV plumbing they always consider the risk of backtracking and put actions/devices in place that will prevent this problem. View the document here.