• 20
    Feb
  • Safety and Patient-Controlled Analgesia: DRUG PRODUCT MIX-UPS

Similar packaging and names of some of the opiates used for PCA have led to errors in drug selection.

Prefilled syringes of meperidine and morphine have been packaged in boxes that look alike. Morphine is available in prefilled syringes in two concentrations, but the packaging might not be helpful for personnel who must quickly distinguish between the strengths. The differences between opiates with and without preservatives are not prominent on labels. All pharmacy-applied labels may look similar on extemporaneously prepared syringes or bags.

A similarity in product names has also resulted in inadvertent mix-ups between morphine and hydromorphone, for example; some staff members have mistakenly believed that hydromorphone is the generic name for morphine. Because opiates are typically available in unit stock, these errors are rarely detected; most often, such mistakes have led to significant overdoses.

PRACTICE-RELATED PROBLEMS

Misprogramming of the PCA pump is, by far, the most frequently reported practice-related error. Problems in pump design that have led to programming errors are described next. canadian cialis

Medication Errors

Other problems that have contributed to PCA errors include the incorrect transcription of prescription drug names into pharmacy computers or Medication Administration Records (MARs). The incorrectly prescribed names are often related to look-alike product names; calculation errors that result when the staff is determining the patient’s dose or rate of infusion; and errors in intravenous (IV) admixtures.

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