Your Prescription for Medication Safety

Instead of discarding unused fentanyl in real time, your anesthesia provider aggregates all discards and brings them out for witnessing by another licensed professional at the end of each day. Sounds like an efficient way to handle discards, right? Wrong.

Here’s the issue: Potential drug diverters may see this process as an opportunity to substitute the fentanyl for a substance like saline. At the end of the day, the witness will only see clear liquid and have no way of discerning the actual contents within.

Thanks in large part to the opioid crisis, your controlled substance practices are under the microscope. Documentation is your best friend here. You need to create an easy-to-follow trail of controlled drug withdrawal from the PACU to the ORs each day, with documentation of the when — and by whom (at least 2 licensed individuals).

To prevent diversion, you’ll want to ensure a licensed individual witnesses discards of partial portions of any controlled substance. Both the discarder and witness should sign off at the time of discard. You should also validate a count of the controlled drug cabinet at the beginning and end of each day.

Many facilities keep their controlled substances in a safe as well as in a PACU cabinet. Your safe will ultimately stave off diverters. First, you’ll need to ensure the safe is appropriately protected and that only a few (I recommend no more than 3) authorized individuals have access to the combination. Generally, this is the clinical director, PACU manager or the “pharmacy nurse” and the medical director or the holder of the controlled drug registration certificate. You’ll also need to ensure the count — a count that should always include expired drugs — within the safe is validated and documented at least monthly or upon the withdrawal of the medication for facility distribution. But keep in mind, some states require more frequent validation/documentation.

When it comes to controlled substances, you should also make every effort to minimize stocking various strengths of drugs. How? Adjust the formulary as much as possible to minimize the calculations of drugs on hand and the potential for error. Many medication errors, especially those involving pediatric patients, are the result of a provider or medication administrator using the wrong strength of a controlled substance. These potentially catastrophic mistakes can be greatly reduced (if not eliminated) through a bare minimum approach to stocking various strengths of drugs. However, this can be difficult — particularly with pediatrics and certain classes of drugs such as anesthetic injectables. If multiple strengths of drugs are essential, distinct “Look-Alike/Sound-Alike” (LASA) drug auxiliary labels, different color narcotic-use forms and separation in storage areas are all proven error-reducing tactics.

You’ll never completely prevent medication mishaps from occurring, but you can come pretty close. Make sure all drug labels for pre-drawn medications have each of the 5 required elements (drug name, strength, time drawn, initials of preparer and date drawn). Have a policy for both multiple- (MDVs) and single-dose vials (SDVs).

• SDVs. For SDVs of drugs like propofol, use the vials for single patients only. Speaking of propofol, you’ll want to stock some sulfite-free versions of the drug for patients with sulfite allergies, and admix propofol with lidocaine just prior to the need whenever possible, and not longer than 1 hour from use. (Note: I prefer separate injections rather than “mixing.”)
• MDVs. MDVs that you use in patient care areas like the OR should be for 1 patient only. Be sure to time-date MDVs used outside of direct patient care areas per the 28-day rule (discarded within 28 days unless the manufacturer specifies a different [shorter or longer] date for that opened vial).

If you stock secured drug samples, you must somehow track everything from their entry into your facility until they’re dispensed. Finally, reversal drugs such as flumazenil, naloxone, methylene blue and lipids (Intralipid, for example) must be readily available.

To prevent common medication errors, use these best practices:

• Avoid “do not use” abbreviations in the medical records to limit the potential for confusion and mistakes.
• Don’t “intermingle” or have compartments of carts or trays with more than 1 drug inside them.
• For handwritten labels, use “Tall Man Lettering” or Upper Case (DOPamine, for example) to highlight distinctive syllables in similar looking drugs.
• For pre-printed labels, color-code by classifications (for example, induction agents in yellow, benzodiazepines in orange, muscle relaxants in fluorescent red, narcotics in blue, vasopressors and hypotensive agents in violet and local anesthetics in gray).
• As with controlled substances, avoid stocking more than one strength of the same drugs unless it’s unavoidable. Lidocaine, for example, require multiple strengths.
• Always separate LASA medications in drug storage areas. Here’s just one example of how easy it is for problems to crop up by not doing so: An anesthesia provider administers a dose of undiluted phenylephrine when he meant to administer a dose of intravenous atropine because the 2 ampoules looked alike and were stored in adjacent locations.

Because you use your emergency/MH cart in high-pressure situations, it’s critical to make sure everything is exactly as it should be on a regular basis. At least monthly, rotating staff members should review the cart contents to ensure widespread familiarity. During the review, make sure all drugs are within the manufacturer’s expiration date (hint: purchase soon-to-expire drugs a month ahead). Your Medical Executive Committee should approve (in writing) your official list of cart contents. Security is paramount, but you’ll want to use breakable locks — as opposed to key locks. Keep replacement locks with managers, not in the cart.

When stocking dantrolene on your MH cart, make sure you have a minimum of 36 vials and at least 2400 mL of sterile water without preservative (preferably in 100 mL vials, not large plastic bags). If you use a newer product such as Ryanodex, ensure you have the correct amount and diluent (osmag.net/tb3FMD). You’ll also want to cross-reference your MH supplies with the Malignant Hyperthermia Association of the United States’ (MHAUS) list of suggested supplies (osmag.net/Nnd5MQ).

If you serve pediatric patients, make sure the pediatric dosage guidelines and pediatric strength meds such as preloaded syringes (atropine and dextrose, for example) are readily available.

When it comes it medication safety, my philosophy has always been to envision myself or a family member was the one lying on the operating table and to ask, “What would I want as the optimum therapies, including drugs, used in the facility?” OSM