Outbreak of Serratia marcescens bloodstream infections in patients receiving parenteral nutrition prepared by a compounding pharmacy.

BACKGROUND: Compounding pharmacies often prepare parenteral nutrition (PN) and must adhere to rigorous standards to avoid contamination of the sterile preparation. In March 2011, Serratia marcescens bloodstream infections (BSIs) were identified in 5 patients receiving PN from a single compounding pharmacy. An investigation was conducted to identify potential sources of contamination and prevent further infections. METHODS: Cases were defined as S. marcescens BSIs in patients receiving PN from the pharmacy between January and March 2011. We reviewed case patients' clinical records, evaluated pharmacy compounding practices, and obtained epidemiologically directed environmental cultures. Molecular relatedness of available Serratia isolates was determined by pulsed-field gel electrophoresis (PFGE). RESULTS: Nineteen case patients were identified; 9 died. The attack rate for patients receiving PN in March was 35%. No case patients were younger than 18 years. In October 2010, the pharmacy began compounding and filter-sterilizing amino acid solution for adult PN using nonsterile amino acids due to a national manufacturer shortage. Review of this process identified breaches in mixing, filtration, and sterility testing practices. S. marcescens was identified from a pharmacy water faucet, mixing container, and opened amino acid powder. These isolates were indistinguishable from the outbreak strain by PFGE. CONCLUSIONS: Compounding of nonsterile amino acid components of PN was initiated due to a manufacturer shortage. Failure to follow recommended compounding standards contributed to an outbreak of S. marcescens BSIs. Improved adherence to sterile compounding standards, critical examination of standards for sterile compounding from nonsterile ingredients, and more rigorous oversight of compounding pharmacies is needed to prevent future outbreaks.

Error-avoidance recommendations for tubing misconnections when using Luer-tip connectors: a statement by the USP Safe Medication Use Expert Committee.

Recommendations are provided to assist health care professionals, manufacturers, and consumers in the appropriate handling of tubing with Luer-tip connectors.

A summary of NICU fat emulsion medication errors and nursing services: data from MEDMARX.

Intralipid infusions remain a critical part of ensuring adequate nutritional supplement and growth in premature and term infants. Managing intralipid therapy requires great care to prevent metabolic and physiological side effects. The authors sought to systematically study medication errors associated with intralipid administration in the neonatal intensive care unit (NICU). A descriptive quantitative and qualitative analysis incorporating secondary data was used. Medication error data were drawn from 54 institutions that voluntarily participated with MEDMARX, a national, Internet-accessible medication error reporting program owned and operated by the United States Pharmacopeia. These errors were associated with NICUs, and each medication error record identified nursing staff as making the initial error. A total of 257 errors were reviewed, with 3.9% resulting in harm. The mean age of the neonate was 7 days, and more errors occurred on Mondays than any other day of the week. Errors disproportionately occurred between 6 pm and midnight, with a significant difference between errors near 7 am and 7 pm (P = .002). Wrong dose errors occurred in 69% of the sample. Nearly one quarter of the errors resulted from misprogramming infusion devices (either pumps or syringes). Qualitative findings revealed that many of the errors were the result of the nurse's misinterpretation of the modes (ie, time, volume, or rate) on the infusion device or by not recognizing the decimal point on the device's display panel. Several errors involved switching the rate of infusion with total parenteral nutrition and that of intralipids. Voluntary medication error reporting offers valuable insights into intralipid errors occurring in NICUs. Secondary analysis is an ethical, economic means of studying the occurrence of such errors. MEDMARX data suggest that some of the serious errors are the result of complex care and equipment needed for these vulnerable infants.

Medication errors in the PACU.

A collaborative research group examined seven years of PACU medication errors from the MEDMARX database. Descriptive statistics showed a comparison of medication errors in all ages from pediatric to adult to geriatric groups. Nine categories of medication errors were noted and a total of 3,023 errors were attributed to errors in prescribing, transcribing, dispensing, administering, and monitoring. Harmful errors were present in 5.8% of the sample, which included two patient deaths. Results indicated that errors can occur in any age group. Organizations and institutions should be aware of these occurrences to ensure vigilance at all times and to focus efforts toward avoiding or decreasing such errors. Patient safety and error prevention recommendations are provided.

Harmful medication errors in children: a 5-year analysis of data from the USP's MEDMARX program.

Harmful pediatric medication errors are common in hospitals and health systems. Understanding what products are involved in these errors is important in the prevention of future errors. We used data from a voluntary medication error reporting system (MEDMARX) and identified 816 harmful outcomes involving 242 medications during a 5-year period. Eleven medications accounted for more than one third of reported errors (n = 261 or 34.5%). Wrong dosing and omission errors were common and were associated with therapeutic classes such as opioid analgesics (e.g., morphine and fentanyl), antimicrobial agents (e.g., vancomycin and gentamicin), and antidiabetic agents (e.g., insulin). Older commonly used agents still resulted in a substantial number of harmful pediatric medication errors and should be included in the focus of patient safety activities.

An overview of intravenous-related medication administration errors as reported to MEDMARX, a national medication error-reporting program.

Medication errors can be harmful, especially if they involve the intravenous (IV) route of administration. A mixed-methodology study using a 5-year review of 73,769 IV-related medication errors from a national medication error reporting program indicates that between 3% and 5% of these errors were harmful. The leading type of error was omission, and the leading cause of error involved clinician performance deficit. Using content analysis, three themes-product shortage, calculation errors, and tubing interconnectivity-emerge and appear to predispose patients to harm. Nurses often participate in IV therapy, and these findings have implications for practice and patient safety. Voluntary medication error-reporting programs afford an opportunity to improve patient care and to further understanding about the nature of IV-related medication errors.

Medication errors in the PACU: a secondary analysis of MEDMARX findings.

Medication errors commonly occur in many health care settings. This review of medication errors illustrates that complex, fast-paced care delivered in PACUs often occurs in an environment where patients encounter numerous processes as they move from preadmission, to preop holding, to the operating room, to PACU, and then back to a clinical unit or discharge. Using a nationally recognized framework, 645 PACU medication error records were analyzed. The errors resulted in a higher than expected threshold of harm (6.8%), with most errors occurring during the administration phase (59%) of the medication use process. Nearly one quarter of the errors involved an improper dose of a medication. Three quarters of the errors were influenced by distractions. More than 130 different products were present in the sample of cases reviewed. Problem areas identified involved epidural analgesia, patient-controlled analgesia, and duplicate doses.

Medication errors in the OR--a secondary analysis of Medmarx.

Although medication errors can result in serious patient complications or even death, a paucity of information regarding medication errors that occur in the OR exists. AORN and the US Pharmacopeia (USP) collaboratively conducted a secondary analysis of reports of medication errors that occurred in the OR. These reports were submitted to the USP via the Medmarx program. The findings will give perioperative clinicians further insight into the types and causes of medication errors that occur in the OR and will help them develop potential prevention strategies.