Health-system pharmacists embrace medication standardization campaign

Completion of Phase I of ASHP’s Standardize 4 Safety initiative is fast approaching.

Branded as the first national effort to standardize medication concentrations with the goal of reducing medication errors, Phase I includes standardization of > 50kg continuous infusions and compounded liquid concentrations. Completion is set for year’s end.

Phase II, < 50kg continuous infusions and standard doses of oral liquids, is scheduled for sometime in 2017. Phases III and IV-intermittent medications, Patient Controlled Analgesia, epidurals, and standard doses of oral chemo agents-are scheduled for 2018.

Deborah PaskoDeborah Pasko, director of ASHP’s Center on Medication Safety and Quality and principal investigator for ASHP’s Standardize 4 Safety campaign, told Drug Topics that standardization is essential because hospitals often use different concentrations of the same medication in different care areas.

“Frequently what we’ve seen happen is that a patient goes to the operating room from the emergency department or an acute care unit and the concentrations are different,” said Pasko.

She pointed out that when a patient goes to an acute care unit, the nurses have to take those infusions down. Then pharmacy has to remake products for them of a different concentration and then they have to re-program all the IV pumps.

“Every time we change a concentration we then have to change everything-including the infusion pump entry, and every time you touch an infusion pump there is a chance for someone to make an error. Every time the pharmacy compounds something there is a chance to make an error. Without standardization you’re significantly increasing your error-risk potential,” said Pasko.

 For example: a doctor writes a prescription for baclofen (Lioresal) used for muscle spasticity in children. The instructions indicate 1 ml per ml one twice a day.  The compounding pharmacy that the patient might go to or the community pharmacy may compound a different concentration than what the prescription was originally written for and the pharmacy, under most state laws, does not need to contact the prescriber to change the concentration. The pharmacy then needs to inform the patient/caregiver of the change in the amount to administer.

Pasko pointed out that under the IV medications arm/continuous infusions, ASHP is recommending weight cut-off categories to encompass pediatric patients and adults; adult sized pediatric patients, and pediatric sized adult patients. “This will help prevent overdosing of medications for both patient populations,” she said.

 Children’s hospitals are high-risk for concentration-related problems because they receive patients from all over the country. “If children have medications that they’re on from a couple of states away, there’s a much higher likelihood that there could be an error if that difference in concentration isn’t caught,” said Mark Thomas, MS, RPh, chief pharmacy director and medication safety officer at Cincinnati Children's Hospital Medical Center.

Thomas noted that with children you’re dealing with a lot of liquids-and that’s where concentrations can become problematic.     “So if somebody can be on a dose of ten milligrams of a drug and that 10 milligrams is in 10 milliliters of a solution and I tell them to take one ml – then it just delivered 1 milligram of the drug. But if that 10 milligrams is only in one milliliter of a solution and I tell them again to take one ml, the patient just got a 10-time overdose of that drug. It’s the strength per milliliter that drives the final dose.” 

   Thomas said that’s why the Institute for Safe Mediation Practices (ISMP) has recommended that you give the milligram dose that you want to give-not just the volume. Thomas asserted that ASHP’s Standardize 4 Safety campaign would have a huge impact on patient safety when patients move from one health care organization to another.

  “If we are successful and our retail partners are on board, we can be safely assured that when a patient is discharged from our hospital and they have their oral liquid medications filled by their retail pharmacy it will be the same concentration and instructions that patient received while they were in our hospital. The chance of human error is greatly reduced.”