Accuracy of the concentration of morphine infusions prepared for patients in a neonatal intensive care unit

Archives of Disease in Childhood

Volumn 98, Issue 12, 2013, Pages 975-979

  Aguado Lorenzo, Virginia ^a   Weeks, Kevin ^a   Tunstell, Paul ^a   Turnock, Karen ^b   Watts, Timothy ^b   Arenas Lopez, Sara ^b  

^a GUY'S AND ST THOMAS' NHS FOUNDATION TRUST   (United Kingdom)

^b EVELINA LONDON CHILDREN S HOSPITAL   (United Kingdom)

Author keywords

[No Author keywords available]

Indexed keywords

MORPHINE;

ARTICLE; DRUG INFUSION; DRUG SOLUTION; HIGH PERFORMANCE LIQUID CHROMATOGRAPHY; HUMAN; INTENSIVE CARE UNIT; NEWBORN; NEWBORN INTENSIVE CARE; PATIENT CARE; PHARMACY; PRIORITY JOURNAL; SAMPLE SIZE;

ACCURACY; INFUSION; MORPHINE; NEONATES; STANDARD CONCENTRATIONS;

ADULT; CHROMATOGRAPHY, HIGH PRESSURE LIQUID; HUMANS; INFANT, NEWBORN; INFUSIONS, INTRAVENOUS; INTENSIVE CARE UNITS, NEONATAL; MEDICATION ERRORS; MORPHINE; PHARMACEUTICAL SOLUTIONS; SYRINGES;

EID: 84888646642     PISSN: 00039888     EISSN: 14682044     Source Type: Journal    
DOI: 10.1136/archdischild-2013-304522     Document Type: Article

References (30)

1. McDowell SE, Mt-Isa S, Ashby D, et al. Where errors occur in the preparation and administration of intravenous medicines: a systematic review and Bayesian analysis. Qual Saf Health Care 2010;19:341-5.
2. Taxis K, Barber N. Ethnographic study of incidence and severity of intravenous drug errors. BMJ 2003;326:684.
3. McLeroy PA. The rule of six: calculating intravenous infusions in a pediatric crisis situation. Hosp Pharm 1994;29:939-40, 43.
4. Guys and St Thomas', King's College and University Lewisham Hospitals. Paediatric Formulary, 8th ed. London, 2010.
5. Vanhole C, Jannes F, Vrancken M, et al. Continuous infusion of medications in very low birth weight infants. Eur J Clin Pharmacol 2004;60:383-6.
6. British National Formulary for Children (BNF-C) 2011-2012, p.793. Pharmaceutical Press, London.
7. Parshuram CS, Ng GY, Ho TK, et al. Discrepancies between ordered and delivered concentrations of opiate infusions in critical care. Crit Care Med 2003;31:2483-7.
8. Beaney AM, Black A. Preparing injectable medicines safely. Nurs times 2012;108:20-3.
9. Hecq JD. Centralized intravenous additive services (CIVAS): The state of the art in 2010. Ann Pharm Francaises 2011;69:30-7.
10. Department of Health. British Pharmacopoeia 2011: Morphine Sulphate Injection. TSO, London, 2011.
11. Choonara I, Lawrence A, Michalkiewicz A, et al. Morphine Metabolism in Neonates and infants. Br J Clin Pharmacol 1992;34:434-7.
12. Wheeler DW, Degnan BA, Sehmi JS, et al. Variability in the concentrations of intravenous drug infusions prepared in a critical care unit. Intensive Care Med 2008;34:1441-7.
13. Parshuram CS, To T, Seto W, et al. Systematic evaluation of errors occurring during the preparation of intravenous medication. CMAJ 2008;178:42-8.
14. Taxis K, Barber N. Causes of intravenous medication errors: an ethnographic study. Qual Saf Health Care 2003;12:343-7.
15. Uppal N, Yassen B, Seto W, et al. Drug formulations that require less than 0.1 mL of stock solution to prepare doses for infants and children. CMAJ 2011;183:E246-8.
16. British Standards Institution. BS EN ISO 7886-1 : 1997. Sterile hypodermic syringes for single use. PART 1. Syringes for manual use. BSI, 1997.
17. Bhambhani V, Beri RS, Puliyel JM. Inadvertent overdosing of neonates as a result of the dead space of the syringe hub and needle. Arch Dis Child Fetal Neonatal Ed 2005;90:F444-5.
18. BD Medical. Technical datasheet BD Plastipak™ Syringe without needle. BD Medical Surgical Systems, 2009.
19. Erstad AJ, Erstad BL, Nix DE. Accuracy and reproducibility of small-volume injections from various-sized syringes. Am J Health-Syst Pharm 2006;63:748-50.
20. Lee SN, Wong AH, Mayer A, et al. Accuracy and reproducibility of syringe measurements. Am J Health-Syst Pharm 1996;53:1166-69.
21. Thobani SU, Steward DJ. The accuracy and variability of bolus injections with different sized syringes. Can J Anaesth 1992;39:198-201.
22. Nunn A, Richey R, Shah U, et al. Estimating the requirement for manipulation of medicines to provide accurate doses for children. Eur J of Hosp Pharm 2012;20:3-7.
23. Worthington T, Tebbs S, Moss H, et al. Are contaminated flush solutions an overlooked source for catheter-related sepsis? Hosp Inf Society 2001;49:81-3.
24. National Patient Safety Agency. Patient Safety Alert 20: Promoting safer use of injectable medicines. London, 2007. http://www.nrls.npsa.nhs.uk/ resources/type/alerts/?entryid45=59812&p=3 (accessed 8 Jan 2013).
25. National Patient Safety Agency. Intravenous morphine administration on neonatal units - signal. London, 2011. http://www.nrls.npsa.nhs.uk/signals/? entryid45=130181 (accessed 8 Jan 2013).
26. Institute of Safe Medication Practice. Medication Safety Alert. Infant's death reinforces need for medications to be dispensed in ready-to-use form. ISMP, 1998. http://www.ismp.org/newsletters/acutecare/articles/19980909-2.asp (accessed 18 Jun 2012).
27. Sentinel Event Alert. Issue 39: Preventing Pediatric Medication Errors. The Joint Commission. http://www.jointcommission.org/sentinel-event-alert-issue- 39-preventing-pediatric-medication-errors/ (accessed 4 Jul 2013).
28. Hilmas E, Sowan A, Gaffoor M, et al. Implementation and evaluation of a comprehensive system to deliver pediatric continuous infusion medications with standardized concentrations. Am J Health Syst Pharm. 2010;67:58-69.
29. Larsen GY, Parker HB, Cash J, et al. Standard drug concentrationsand smart-pump technology reduce continuous-medication-infusion errors in paediatric patients. Paediatrics 2005;116:e21-5.
30. Poon EG, Keohane CA, Yoon CS, et al. Effect of Bar-Code Technology on the Safety of Medication Administration. N Eng J Med 2010;362:1698-707.