1304 / Labeling of syringes with injectable drugs

SPAIN
Classification of the PSP
Type of Patient Safety Practice Not Evaluated
 
Clinical Practice (CP)
Related practices from PaSQ database
"Best fit" category of the reported practice
Medication / IV Fluids
Medical devices / Equipment There is no specified text here
Topic of the reported practice
Clinical risk management
Aim and the benefit of the Patient Safety Practice
 
During anesthesia there is a significant risk that errors occur in the administration of medications, since many drugs are administered, often simultaneously. It is often cited that a medication error occurs for every 133 anesthetic procedures. The error rate to cause adverse effects to patients is higher than in other areas, which is attributed to the characteristics of drugs used. It is estimated that 1 out of 20 errors registered is serious and 1 out of 250 is fatal. The most common medication errors related with anesthesia include the use of incorrect syringes and vials, delivery devices errors and errors related with the method of administration, especially intravenous and epidural routes. There are recommendations for the labeling of syringes loaded with injectable medication used during anesthesia to reduce the risk
Description of the Patient Safety Practice
 
In response to the notification of a medication administration incident, the use of adhesive tags to identify drug syringes was proposed, following the international standard. In 2013, the Safety Patient Unit accepted the use of the consensus document of SENSAR- ISMP – Spain (2011). In this document, the Institute for Safe Medication Practices (ISMP-Spain), in collaboration with the Spanish Security Reporting System Anesthesia (SENSAR) gives a series of recommendations aimed at preventing medication errors caused by the failure to identify preparations and routes of administration, and includes the adoption of a standard color code in the European Union for labeling syringes in anesthesia.
After, a report to justify their need and assess annual consumption in order to estimate the amount needed for the management of purchasing this material was made. It also requested to the Anesthesia Service the list of drugs that should be labeled.
With all these reports, the request was made nine months after the purchase was authorized, establishing a trial period of the two models received, as a pilot, and establishing mechanisms for purchase and distribution.
In April 2014 a broadcast of an informative video on the use of identification tags is approved. After the pilot, we chose one of the two systems, and in September 2014, labels began to be used in all operating rooms, including emergency, reanimation and the endoscopy unit.
Up today they are in use and all the professionals who have been asked, both anesthetists and nurses, are extremely satisfied with the improvement in safety and ease of use of the system..
After a year, this practice is going to spread to all hospitals in the region, including medication infusion.
Attachment of relevant written information and/or photos, as appropriate
There is no specified text here
There is no specified text here
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Effectiveness of the Patient Safety Practice
 
Degree of implementation of reported practice
Yes, fully
Level of implementation of reported practice
Institution level
Specific and measurable outcome for the reported practice were defined
No
A baseline measurement before implementation of the reported practice was obtained
No
A measurement after full implementation of the reported practice was obtained
Yes
Evaluation of a "positive" effect of the reported practice on Patient Safety
The evaluation showed improvements in Patient Safety outcomes
Type of before-and after evaluation
Qualitative
Enclosure of a reference or attachment in case of published evaluation's results
There is no specified text here
There is no specified text here
Health care context where the Patient Safety Practices was implemented
 
Hospital
Transferability
 
Successful implementation of this Patient Safety Practice in other health care settings than above stated
Not known
Specification of implementation in another health care setting(s)
There is no specified text here
Successful implementation's level  of this Patient Safety Practice across settings
There is no specified text here
Involved health care staff
 
Physicians
Nurses
Clinical manager
Quality manager
Risk manager
Patient Involvement
 
Direct service user's involvement as integral part of this Patient Safety Practice
No
Specification of the service users or their representatives' involvement in the implementation of this Patient Safety Practice
There is no specified text here
Point of time in which service user or their reprasentatives' involvement takes place
There is no specified text here
Active seeking of service users' opinion, feedback, experience, etc. as integral part of this Patient Safety Practice
There is no specified text here
Short description of the service users' level of involvement
There is no specified text here
Public accessibility of information regarding this Patient Safety Practice to patients and citizens/service users
No
List of sources where public information is accessible
There is no specified text here
Implementation of the Patient Safety Practice
 
Existing collaboration with other countries or international organisations related to implementation of this Patient Safety Practice
No
Problems encountering in the implememntation course of this Patient Safety Practice like lack of motivation, no management support, etc.
No
List of the most prevelent difficulties encuntered during implementation of this Patient Safety Practice
There is no specified text here
List of the most prevalent drivers for a successful implemetation of this Patient Safety Practice
Staff and management recognised the need for change
Use of any specific incentives to enhance motivation while implementing this Patient Safety Practice
No
Description of used incentives, if any.
There is no specified text here
Existence of support or approval by the clinical or hospital management or any other hihg level authority in the implementation process of this Patient Safety Practice
Yes
Costs of the Patient Safety Practices
 
Completion of cost calculation related to this Patient Safety Practice
Yes
Total number of person days required to implement this Patient Safety Practice
Clinical staff: 10
External consultants: 0
Support staff: 0
Managerial staff: 2
Others: 0
Not relevant: 0
Total number of person days required for training as preparation for implementation of this Patient Safety Practice
Clinical staff: 2
External consultants: 0
Support staff: 0
Managerial staff: 0
Others: 0
Not relevant: 3500
Total cost in Euro of specific equipment (machines, software, communications supplies, etc.) needed to support implementation of this Patient Safety Practice
0
Associated cost with a work reduction or foregoing in order to deliver this Patient Safety Practice
0
Contact information
 
Name: Julian Alcaraz Martinez
Country: SPAIN
Organisation: Hospital Morales Meseguer. Murcia
E-mail: julian.alcaraz2@carm.es
Phone: 0034636047506
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