Medication safety alerts

An up-to-date list of Australian and international medication safety alerts can be found on the Australian Commission on Safety and Quality in Health Care website (external site).

Intravenous potassium chloride

In October 2003, the Australian Council for Safety and Quality in Health Care released a medication safety alert.1

This alert outlined the fatal nature of intravenous potassium chloride if administered inappropriately.

In response to this alert, an expert working group of the WA Medication Safety Group released a policy (July 2005) for the use of intravenous potassium chloride. This policy was updated in 2013.

Vincristine

In December 2005, the Australian Council for Safety and Quality in Health Care released a Medication Safety Alert.2

This alert outlined the fatal risks of wrong route administration of vincristine. In response to this alert, an expert working group of the WA Medication Safety Group released a Policy (November 2006) for the use of intravenous vincristine.

Heparin and neonates

In September 2006, the IndyStar.com website published the article Methodist rolls out medical safeguards (external site) which was in regard to the inadvertent overdose of heparin to neonates through use of adult strength heparin at Methodist Hospital (USA).

Six of the neonates received overdoses, of which 2 were fatal.

A number of organisational changes were made to prevent reoccurrence of this event at Methodist Hospital:

  • hospital no longer stocks adult strength vials of heparin that are similar to neonatal vials
  • pharmacy to double-check all drugs taken from storeroom to wards
  • at least 2 nurses to validate doses before giving neonates
  • mass staff education on safe drug administration

In Western Australia, the current situation regarding the storage and use of heparin is as follows:

  • generally use pre-prepared heparinised saline for IV flushes rather than putting heparin into saline and use saline alone where possible (for adults)
  • heparinised saline is not used for line flushes in special care nursery (SCN) at KEMH
  • for infants/neonates usual practice is for pharmacy to make correct solution (heparin plus glucose or glucose/NaCl) and deliver to ward as required
  • administration is checked by 2 nurses (as well as on issue by pharmacy)
  • at KEMH heparin is also kept on imprest for use after hours (1000units/1 mL, nursing staff would add 50 units to 100 mL dextrose for infusion solutions (and administer 1 mL of solution)
  • ward imprest of heparin is kept in a fridge – drug is always kept in manufacturer's packaging
  • adult strength concentration (5000 units/0.2 mL) is not kept on ward but is available in pharmacy
  • glass ampoules for 1000 units/1 mL and 5000 units/0.2 mL are visually similar, although the volume of liquid in each ampoule is different.

References

More information

Quality Improvement and Change Management Unit
Address: 189 Royal Street, East Perth
Phone: 9222 4080
Email: qicm@health.wa.gov.au

Last reviewed: 30-09-2016
Last updated: 19-04-2017
Produced by

Quality Improvement and Change Management Unit