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Publication Type: Risk Alert
Single or Multiple Incident: Multiple
Date: 7/1/2021 12:00:00 AM
Country: Hong Kong
This alert describes four incidents of medication errors involving high-alert medications. Two cases involved administration of subcutaneous morphine and IV midazolam, respectively, at the wrong infusion rate using a syringe pump. In another case IV morphine was administered at the wrong rate using a smart infusion pump. The last case described a high serum potassium level after administration of potassium chloride infusion; no cause was cited. Guidelines when administering high-alert drugs are provided.

Additional Details

Device:
syringe pump, smart infusion pump
Medication/Gas/Fluid:
potassium chloride IV, morphine - subcutaneous, IV, midazolam IV
Medication/IV List:
moderate sedation agents, IV , narcotics/opiates, IV, transdermal, and oral

Rules / Policies / Procedures
  1. Perform independent double check on the 5 Rights (right patient, right time, right drug, right dose and right route) against the prescription and pump settings before commencing the infusion and leaving the patient. Be cautious of decimal points.
  2. Make reference to standardised dosing/infusion tables to minimise calculation errors.
  3. Use commercially pre-mixed IV/epidural solutions if available.
  4. Keep only one strength of parenteral narcotic/opioids in the ward (if applicable).
Training
  1. Display drug information charts for easy reference to medical, nursing and pharmacy staff, e.g. compatibility, maximum dose and equianalgesic doses for opioids in all patient care units.

Medication Error - High alert medication infusion