Medication safety alerts
An up-to-date list of Australian and international Medication Safety alerts can be found on the Australian Commission On Safety and Quality in Health Care website.
KCI
In October 2003, the Australian Council for Safety and Quality in Health Care released a Medication Safety Alert. 3 This alert outlined the fatal nature of intravenous potassium chloride if administered inappropriately. In response to this alert, an expert working group of the WA Medication Safety Group released a Policy (July 2005) for the use of intravenous potassium chloride.
- KCI Medication Safety Alert (PDF 208KB)
- Policy for use of intravenous potassium chloride (Operational Circular)
Vincristine
In December 2005, the Australian Council for Safety and Quality in Health Care released a Medication Safety Alert. 4 This alert outlined the fatal risks of wrong route administration of vincristine. In response to this alert, an expert working group of the WA Medication Safety Group released a Policy (November 2006) for the use of intravenous vincristine.
- Vincristine Medication Safety Alert (PDF 68KB)
- Policy for the Safe Administration of Vinca Alkaloid Drugs (Operational Directive)
Heparin and neonates
In September 2006, an article (PDF 111KB) was published regarding the inadvertent overdose of heparin to neonates through use of adult strength heparin at Methodist Hospital (USA). Six of the neonates received overdoses, of which two were fatal.
A number of organisational changes were made to prevent reoccurrence of this event at Methodist Hospital:
- Hospital no longer stocks adult strength vials of herapin that are similar to neonatal vials
- Pharmacy to double-check all drugs taken from storeroom to wards
- At least two nurses to validate doses before giving neonates
- Mass staff education on safe drug administration
In Western Australia, the current situation regarding the storage and use of heparin is as follows:
- Generally use pre-prepared heparinised saline for IV flushes rather than putting heparin into saline and use saline alone where possible (for adults)
- Heparinised saline is not used for line flushes in SCN at KEMH
- For infants/neonates usual practice is for Pharmacy to make correct solution (heparin plus glucose or glucose/NaCl) and deliver to ward as required
- Administration is checked by two nurses (as well as on issue by Pharmacy)
- At KEMH heparin is also kept on imprest for use after hours (1000units/1mL0, nursing staff would add 50 units to 100mL dextrose for infusion solutions (and administer 1mL of solution)
- Ward imprest of heparin is kept in a fridge, drug is always kept in manufacturer's packaging
- Adult strength concentration (5000units/0.2mL) is not kept on ward but is available in Pharmacy
- Glass ampoules for 1000units/1mL and 5000units/0.2mL are visually similar, although the volume of liquid in each ampoule is different
3 Medication Safety Task Force of the Australian Council for Safety and Quality in Health Care. Medication Alert - Intravenous potassium chloride. October 2003
4 Australian Council for safety and Quality in Health care. Medication Alert - Vincristine. December 2005
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