RESUMO
AIMS: To describe the implementation of safety systems for the use of intravenous potassium chloride in haematology patients. METHODS: We assessed the use of intravenous potassium in a haematology ward at a tertiary hospital. Initially, we prospectively analysed the prescribing and administration of intravenous potassium to all patients over a two-week period. To complement this data, we retrospectively analysed all clinical incidents involving intravenous potassium and the dispensing patterns of potassium ampoules for the past 12 months. Drawing on evidence and recommendations from international safety literature, gaps in the safe use of potassium were identified, and a multi-factorial approach to system change was implemented. RESULTS: A total of 18 patients were analysed with 90 intravenous bags of potassium prepared on the ward using 624 ampoules. We identified multiple opportunities for error and a lack of standardisation of therapy. The following safety systems were introduced: (i) a new prescribing and monitoring form that included dose calculation, prescriber support and pre-printed orders; (ii) removal of potassium ampoules and introduction of premixed bags; (iii) independent double checking by nursing staff at point of administration; (iv) dedicated labelling of intravenous lines; (v) extensive clinician training supported by guidelines; and (vi) introduction of 'smart pump' infusion software. The number of incidents significantly reduced from 23 to 9 (p < 0.001), and the number of ampoules dispensed reduced from 10,100 to 0. CONCLUSIONS: A multi-factorial approach to the safe prescribing, dispensing and administration of intravenous potassium has reduced the potential for patient harm in the haematology setting.
Assuntos
Hematologia/métodos , Erros de Medicação/prevenção & controle , Cloreto de Potássio/administração & dosagem , Cloreto de Potássio/efeitos adversos , Química Farmacêutica , Sistemas de Liberação de Medicamentos/instrumentação , Cálculos da Dosagem de Medicamento , Embalagem de Medicamentos , Desenho de Equipamento , Hematologia/normas , Humanos , Bombas de Infusão , Infusões Intravenosas , Segurança do Paciente , Serviço de Farmácia Hospitalar , Avaliação de Programas e Projetos de Saúde , Estudos Prospectivos , Melhoria de Qualidade , Indicadores de Qualidade em Assistência à Saúde , Queensland , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Software , Centros de Atenção Terciária , Fatores de Tempo , Resultado do TratamentoRESUMO
On-line imaging of prostate markers can be used to compensate for errors in radiation delivery. This study assessed the patient acceptability and morbidity associated with the trans-perineal route of implantation. A minority experienced acute pain or bleeding. Placement was accurate in all but one subject. An operator related learning curve exists. Although this is an invasive procedure most patients found it acceptable. Implementation for routine clinical practice is feasible.