Pamela Bevelhymer LOOK CLOSELY Some medications have similar names, but treat very different conditions, such as acetohexamide and acetazolamide.
Ensuring the medications used in your facility are administered properly, stored correctly and wasted appropriately is an ongoing challenge. Answering these eight questions and checking out the advice-filled responses will help you find out if your understanding of proper drug labeling, security and disposal practices makes the grade.
1. About _____ of nurses will suffer from substance use disorder during their careers, according to the American Nurses Association.
Answer: b
Keep an eye out for the warning signs of addiction, suggests Zachary Bouchat-Friedman, PharmD, a staff pharmacist at Allegheny Valley Hospital in Natrona Heights, Pa. Warning signs include employees who are frequently late, calling out sick, disappearing for extended periods of time while on the clock. Other red flags include pinpoint pupils, an unkempt appearance and a history of disciplinary actions or mistakes. "These employees will often blame the environment or others for their mistakes, and will claim to experience frequent personal emergencies," says Dr. Bouchat-Friedman.
Also be suspicious of providers whose patients report little to no pain relief. "A nurse could easily scan a medication and the patient's ID — thereby completing the administration documentation — and simply omit the controlled substance dose or administer a 'dummy' injection in its place," says Dr. Bouchat-Friedman. Close
METICULOUS MONITORING Don't let your facility's medication storage and disposal protocols fall through the cracks.
2. Which of the following is the most commonly diverted medication, according to the Drug Enforcement Administration?
Answer: c
Theft of a controlled substance is a felony, but the guilty party can simply move to another state and easily attain another job (depending on how thorough the new employer is in conducting a background check), according to Dr. Bouchat-Friedman. Keep in mind that some providers who suffer from substance use disorder might not display any warning signs — they're smart and careful, and go to great lengths to avoid being caught. That's why it's essential to closely monitor the dispensing and waste of all controlled substances, and keep them secure until they're needed.
He says medication safeguards should be strict and effective. "All controlled substances must be stored separately in a secure location," he explains. "Document every dispense and return, and require a blind count by a staff member. Most of the controlled substances in our hospital are delivered to automated storage cabinets, which electronically log dispenses, returns and waste by providers."
Disposal of leftover doses (a partial tablet or an unemptied vial) requires a second individual's (witness) signature. The wasted portion should be placed into a controlled substance waste management system, which automatically secures pharmaceuticals and renders them unusable. These systems should be within easy access of where medications are administered to allow for the proper disposal of solid and liquid controlled substances. Additionally, store expired controlled substances in a secure location until they are processed and disposed of by a third party, notes Dr. Bouchat-Friedman.
Allegheny Valley Hospital's pharmacy has begun auditing controlled substances used in the OR with refractometer technology. "We can test injectable medications, both undiluted and prepared, at specific concentrations in the OR, all of which have an identifiable signature," says Dr. Bouchat-Friedman. "By using software to compare the sample against a known database, we can determine if diversion might be taking place. Regular auditing is a network-wide safety measure due to anesthesia professionals having such a high incidence of abuse in their profession." Close
3. You should spike IV solutions within how many hours of their intended use?
Answer: a
Standards and recommendations from the Association for Professionals in Infection Control and Epidemiology (APIC) and the United States Pharmacopeia (USP) indicate IVs should be spiked as close to the intended administration time as possible. At the very least, bags must be spiked within one hour of their intended use, according to Sheldon Sones, R.Ph., FASCP, president and founder of Sheldon S. Sones and Associates in Newington, Conn. "In the past, we would see several IVs spiked hanging for use the next morning," he says. "The one-hour rule is now standard practice." Close
HIGH RISK Opioids, benzodiazepines and amphetamines are the most commonly diverted controlled substances.
4. A patient claims to be allergic to sulfa medications, which have caused him to suffer major body rashes. Is it necessary to alert anesthesia of the reported allergy to sulfas because some forms of propofol contain sulfites?
Answer: b
Sulfa drugs treat a variety of health conditions, including common infections, while sulfites are preservatives used in foods, drinks (especially wine) and medications. "Sulfa drugs and sulfites are not related," explains Mr. Sones. "Neither are their allergies, so there is no need to worry about administering propofol to a patient who is allergic to sulfas." Close
5. How much dantrolene is needed to treat malignant hyperthermia in a patient weighing 70 kg?
Answer: c
An initial dose of dantrolene at 2.5 mg/kg is recommended, with a suggested upper limit of 10 mg/kg. If the patient weighs 70 kg, at least 700 mg is needed. Dantrium and Revonto, two dantrolene products, come packaged in 20 mg vials. Each vial should be reconstituted for injection by adding 60 ml of sterile water and shaken until the solution is clear. Ryanodex, a third dantrolene option, is packaged in 250 mg vials. It must be reconstituted with 5 ml of sterile water and shaken into an orange-colored opaque suspension. In order to have enough dantrolene on hand to administer the initial dose, you must stock 30 vials of Revonto and Dantrium, and three vials of Ryanodex. Close
6. Which two medications are used to treat glaucoma and anxiety, respectively?
Answer: a & d
Acetazolamide is the generic form of Diamox. It's a sulfur-containing product that is used to relieve intraocular pressure caused by glaucoma. Acetohexamide is the generic form of Dymelor, an older antidiabetic drug. Hydroxyzine is the generic version of Vistaril or Atarax and can be used to address anxiety. It can also be used to treat nausea and itching. Hydralazine is an antihypertensive, with a trade name of Apresoline. These drugs have very different uses but are easily confused because they have similar sounding names. When handling Look Alike/Sound Alike (LASA) medications, be sure to separate them in drug storage areas. If their labels are handwritten, use tall man lettering — writing part of a drug's name in capital letters — to differentiate it from similar-looking drugs. When using pre-printed labels, color-code drugs based on their classifications to help avoid confusion during administration.
Keep in mind that guidelines issued by the American Society of Anesthesiologists say all labels on vials and ampoules must contain the drug's generic name, concentration, total volume or contents, manufacturer, lot number, date of manufacturing and expiration date. Additionally, providers must note the drug, strength, date and their initials on labels affixed to syringes that will be used in the OR. Close
7. A patient indicates a "significant allergy" to Percocet on an admission report. The PRN list for pain management lists several drugs and looks like the example below (the checkmarks indicate the prescriber's endorsed orders). What's your next step?
If the patient cannot take Percocet, administer fentanyl 50 mcg x1; may repeat in 15 minutes one time only
Oxycodone with APAP x1 as needed one time only
Tramadol 50 mg PRN for pain
Acetaminophen with Codeine #3 PRN for pain
Dilaudid 2 mg PO x1 if oxycodone/APAP is ineffective
Call the prescriber.
Oxycodone with APAP is Percocet. If a patient is allergic to Percocet, then oxycodone with APAP is the same thing. "This example reaffirms the need to correlate stated allergies and side effect declarations to endorsed medication orders," says Mr. Sones. Close
Sheldon Sones
8. How should you address the potential for error shown in this picture?
Answer: These various medications need to be separated. Mr. Sones says drug storage areas must not allow for "intermingling" of a number of different agents. The epinephrine vials shown in this photo contain different concentrations, which could lead to confusion when they're pulled for use. Allocating sufficient space for drug storage allows for segregation of each drug and concentration, points out Mr. Sones.
He emphasizes that concentrated electrolytes should be stored away from other inventory to help ensure staff are aware the solutions need to be diluted before administration. Mr. Sones also says neuromuscular blockers should be stored in separate lidded containers or a secured storage area. Additionally, according to a safety alert issued by the Institute for Safe Medication Practices (ISMP), neuromuscular blockers should be kept only in areas where they are routinely needed. Warning labels should be placed on their storage containers to alert staff of the risk of respiratory paralysis and the need to ventilate patients who receive them, recommends the alert. Close
OSM
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