Evaluación del cumplimiento del protocolo de utilización de cloruro potásico

  1. Fernández Bargiela, Noelia
  2. Salvador Garrido, Pilar
  3. Pedreira Vázquez, Isaura
  4. González Piñeiro, Sara
  5. Martín Herránz, María Isabel
Journal:
Ars pharmaceutica

ISSN: 2340-9894,  0004-2927

Year of publication: 2017

Volume: 58

Issue: 2

Pages: 67-73

Type: Article

DIALNET GOOGLE SCHOLAR lock_openOpen access editor

More publications in: Ars pharmaceutica

Abstract

Objective: To analyze the degree of compliance with the “Guidelines for the safe use of potassium chloride” implemented in our hospital, using periodic audits, during the period 2013-2016. Methods: Descriptive study of the audits carried out at 6 months post-implementation (beginning of 2013) and then every year (2014-2016). The evaluation indicators were developed following the recommendations included in the Guidelines and referred to storage, prescription, preparation and administration of potassium solutions. The patient care units evaluated are: critical care authorized units (storage and independent double checks during preparation of solutions and before its administration) and all patient care units (prescription and correct labeling for its correct administration). Results: There were audited 55 patient care units, which showed a compliance of 100% for the prescription and correct labeling indicators. Of those units, 12 (critical and emergency units) are authorized to have concentrated potassium chloride ampoules 1M. These 12 units did not have a correct compliance with the other two indicators, because one unit did not show a correct storage (in 2014) and the double check required was not verified by 3 units in 2013, one in 2014 and 2015. Conclusion: The audits showed the correct follow-up with the Guidelines for most of the evaluated criteria, however demonstrated the need to carry out periodic strategies of intensification and remembrance to guarantee the correct compliance of all the established recommendations.

Bibliographic References

  • Kohn LT, Corrigan JM, Donaldson MS, editores. To Err is human: Building a safer health system. Committee on Health Care in America. Institute of Medicine. Washington, DC: National Academy Press; 1999.
  • Committee on Health Care in America. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washintong, DC:National Academy Press; 2001.
  • Joint Commission on Accreditation of Healthcare Organization (JCAHO). 2003 National Patient Safety Goals.
  • Expert Group on Safe Medication Practices. Creation of a better medication safety culture in Europe: Building up safe medication practices. 2006.
  • The National Quality Forum. Safe Practices for Better Healthcare: A Consensus Report. Washington, DC: National Quality Forum; 2003 (Document NQFCR-05-03).
  • Australian Council for Safety and Quality in Healthcare Medication Safety Taskforce. Intravenous potassium chloride can be fatal if given appropriately. Australian Council for Safety and Quality, 2003.
  • ISMP Canada, Ontario Hospital Association. System safeguards to prevent error induced injury with potassium chloride, 2003.
  • Institute for Safe Medication Practices. ISMP´s list of high-alert medications. Huntingdon Valley (PA): ISMP; 2012. Disponible en: http://www.ismp.org/Tools/highalertmedications.pdf.
  • Centro Colaborador de la OMS sobre Soluciones para la Seguridad del Paciente. Control de las soluciones concentradas de electrolitos. Soluciones para la seguridad del paciente. Volumen 1, solución 5. Mayo 2007.
  • Belyamani L, Elmoqadem A, Elbaite A, Mounir K, Drissi Kamili N. Paraplégie après administration péridurale accidentelle de chlorure de potassium. Annales Françaises d’Anesthésie et de Réanimation 2008: 27: 111-3.
  • Wetherton AR, Corey TS, Buchino JJ, Burrows AM. Fatal Intravenous Injection of Potassium in Hospitalized Patient. Am J Forensic Med Pathol 2003; 24:128–131.
  • Kapitan C. Poor penmanship costs doctor $380,000. San Antonio Express-News website. http://www.mysanantonio.com/business/health-care/article/Jury-Doc-s-sloppy-handwriting-factored-infatal-4866905.php.
  • Asensio Martín MJ, Herrero de Lucas E, Estébanez Montiel B, García de Lorenzo y Mateos A. Alteraciones del potasio. Medicine 2015; 11: 4739–47.
  • Recomendaciones para el uso seguro del potasio intravenoso. ISMP-España. Disponible en: http://www.seguridaddelpaciente.es/formacion/tutoriales/MSC-CD4/.
  • Leape LL, Bates DW, Cullen DJ, et al. Systems Analysis of Adverse Drug Events. JAMA 1995; 274: 35-43.
  • Apkon M, Leonard J, Probst L, et al. Design of a safer approach to intravenous drug infusions: failure mode efects analysis. Qual Saf Health Care 2004; 13: 265–271.
  • Nichols P, Copeland T, Craib I, et al. Learning from error: identifying contributory causes of medication errors n an Australian hospital. MJA 2008; 188: 276–9.
  • Pearson P, Steven A, Howe A, Sheikh A, Ashcroft D, Smith P. Patient Safety Education Study Group. Learning about patient safety: organizational context and culture in the education of health care professionals. J Health Serv Res Policy 2010; 15: 4-10.
  • Estudio nacional sobre los efectos adversos ligados a la hospitalización. Estudio ENEAS. Madrid: Ministerio de Sanidad y Consumo; 2006.
  • Plan de Calidad para el Sistema Nacional de Salud. Ministerio de Sanidad y Consumo. http://www.mspsi.es/organizacion/sns/planCalidadSNS/pdf/pncalidad/PlanCalidad2010.pdf.
  • Pastó-Cardona L, Masuet-Aumatell C, Bara-Oliván B, Castro-Cels I, Clopés-Estela A, Pàez-Vives F, Schönenberger-Arnaiz JA, Gorgas-Torner MQ, Codina-Jané C. Estudio de incidencia de los errores de medicación en los procesos de utilización del medicamento: prescripción, transcripción, validación, preparación, dispensación y administración en el ámbito hospitalario. Farmacia Hospitalaria 2009: 33: 257-68.
  • Runciman W, Hibbert P, Thomson R, Van Der Schaaf T, Sherman H, Lewalle P. Towards an International Classification for Patient Safety: key concepts and terms. Int J Qual Health Care 2009; 21: 18-26.
  • National Medication Safety Guidelines Manual. Singapore. https://www.moh.gov.sg/content/dam/moh_web/Publications/Guidelines/Other%20Guidelines/2013/National_Medication_Safety_Guidelines_Manual_Final.pdf.
Data source: Dialnet