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Experiencia con la implementación del uso de soluciones estandarizadas de cloruro de potasio
Experience with implementation of standardized using potassium chloride solutions
A experiência com a implementação da normalizada, utilizando soluções de cloreto de potássio
Keywords:
Seguridad del Paciente, Efectos Colaterales y Reacciones Adversas Relacionados con Medicamentos, Errores de Medicación, Prescripciones de Medicamentos, Potasio (es)Patient Safety, Drug-Related Side Effects and Adverse Reactions, Medication Errors, Drug Prescriptions, Potassium (en)
Segurança do Paciente, Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos, Erros de Medicação, Prescrições de Medicamentos, Potássio (pt)
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El cloruro de potasio es un medicamento de alto riesgo que se utiliza frecuentemente en los hospitales. En el Hospital Pablo Tobón Uribe se conformó un grupo para liderar la implementación de una práctica segura para el uso de este medicamento. Inicialmente, se realizó un diagnóstico y con sus resultados se definió el retiro de las ampollas de cloruro de potasio de las unidades asistenciales, la prescripción de mezclas estandarizadas con este electrolito para pacientes pediátricos y adultos y su preparación centralizada por el Servicio Farmacéutico. Se hizo un seguimiento para evaluar la adherencia a la práctica implementada, en el que se encontró
un cumplimiento del 91,2%, sin presencia de viales almacenados en las unidades donde se restringió; además, se encontró la no influencia en las tasas de flebitis en comparación con meses previos al uso de estas mezclas y el reconocimiento de los riesgos inherentes al uso de un medicamento como el cloruro de potasio dentro del personal asistencial. En el momento actual, esta práctica continúa ejerciéndose en la institución, aunque se han tenido
mejoras de acuerdo a los hallazgos en los seguimientos realizados. Por lo tanto, es modelo a seguir para la implementación de otras medicaciones y mezclas que contienen electrolitos.
Potassium chloride is a high-risk medication frequently used in hospitals. In the Hospital Pablo Tobón Uribe, a group was formed to lead the implementation of a safe practice for the use of this medicine. Initially a diagnosis was made, whose results were the removal of potassium chloride ampoules from the care unit, the prescription of standardized electrolyte mixtures for pediatric and adult patients, and their centralized preparation by the Pharmaceutical Service defined. It were followed to assess adherence to the practice implemented by finding a fulfillment of 91,2%, without the presence of vials stored in the units was restricted and no influence was found on phlebitis rates compared to previous months of the use of these mixtures. In addition, it was recognized the inherent risks of the use of a drug such as potassium chloride within the care team. At present, this practice is still exerted at the institution; there have been improvements in accordance with the findings in the monitoring process. It is model for implementation with other medications and mixtures containing electrolytes.
O cloreto de potássio é um medicamento de alto risco é freqüentemente usado em hospitais. No Hospital Pablo Tobón Uribe, um grupo foi formado para liderar a implementação de práticas seguras para o uso deste medicamento. Inicialmente, o diagnóstico foi feito e os seus resultados a remoção da unidade de cloreto de potássio ampolas cuidado, a prescrição padronizada com este misturas eletrólitos para pacientes pediátricos e adultos, e sua preparação centralizadas da Assistência Farmacêutica definida. Foram seguidos para avaliar a adesão à prática implementada por encontrar uma realização de 91,2%, sem a presença de frascos armazenados nas unidades e foi restrito nenhuma influência sobre as taxas de flebite comparação com meses anteriores, com a utilização dessas misturas. Além disso, o reconhecimento dos riscos inerentes ao uso de uma droga, como cloreto de potássio dentro da equipe assistencial. Actualmente, esta prática continua a ser exercida na instituição tem havido melhorias, de acordo com as conclusões dos acompanhamentos. É modelo para a implementação com outros medicamentos e misturas contendo eletrólitos.
References
(1) Richardson WC, Berwick DM, Bisgard C, Bristow L, Buck CR, Coye J et al. To err is human: building a safer health system [report on the Internet]. Washington: Institute of Medicine; 2000 [access: 2012 Aug 20]. Available from: http:// www.iom.edu/Reports/1999/To-Err-is-HumanBuilding-A-Safer-Health-System.aspx
(2) Bates DW. Preventing medication errors: a summary. Am J Health Syst Pharm. 2007 Jul;64(14 Suppl 9):S3-S9.
(3) Aranaz JM, Aibar C. Estudio ibeas. Prevalencia de efectos adversos en hospitales de Latinoamérica. Madrid: Ministerio de Sanidad y Política Social; 2010.
(4) Wittich CM, Burkle CM, Lanier WL. Medication errors: an overview for clinicians. Mayo ClinProc. 2014 Aug;89(8):1116-1125.
(5) Keohane CA, Bates DW. Medication safety.Obstet Gyn Clin N Am. 2008 Mar;35(1):37-52.
(6) World Health Organization (who). La oms lanza “Nueve soluciones para la seguridad del paciente” a fin de salvar vidas y evitar daños [comunicado de prensa en Internet]. Washington/Ginebra: World Health Organization; c2007 [actualizado: 02 may 2007; acceso: 24 ago 2014].Centro de prensa [aprox. 3 pantallas]. Disponible en: http://www.who.int/mediacentre/news/releases/2007/pr22/es/
(7) The Leapfrog Group [homepage on the Internet]. Washington dc: Leapfrog Group; c2003.[updated: 2014 Aug 24; access: 2014 Aug 24].
Available from: http://www.leapfroggroup.org/
(8) Gorrell JJ, Patterson CB, Spence CE, High J,Covelli B. Joint Commission readiness: incorporating the national patient safety goals and medication management standards into daily practice. En: 42nd ashp Midyear Clinical Meeting and Exhibition. Las Vegas: ashp Midyear Clin Meeting; 2007.
(9) Tomsic M. Critical supply [Internet]. Agency for Healthcare Research and Quality. National Public Radio, 2013 [access: 2013 Apr 5]. Available from: http://psnet.ahrq.gov/resource.aspx?resourceID=25917&sourceID=1&emailID=
(10) Institute For Safe Medication Practices (ismp). ismp list of high-alert medications in acute care settings [report on the Internet]. Huntingdon Valley (PA): ismp; 2012 [access: 2014 Dec 13].
Available from: http://www.ismp.org/Tools/highalertmedications.pdf
(11) Tubman M, Majumdar SR, Lee D, Friesen C,Klassen TP. Best practices for safe handling of products containing concentrated potassium. bmj. 2005 Jul;331(7511):274-277.
(12) Melissa MH, Azmi S. Drug utilization review of potassium chloride injection formulations available in a private hospital in Kuching,Sarawak, Malaysia. Malays J Med Sci. 2013Jul;20(4):47-55.
(13) Lakhani M, Stewart WK. Hazards of potassium chloride solution. Lancet. 1985 Aug;2(8452):453.
(14) Australian Council for Safety and Quality in Healthcare. Intravenous potassium chloride can be fatal if given inappropriately. Canberra: Australian Council for Safety and Quality in Healthcare; 2003.
(15) Cornish P, Hyland S, Koczmara C. Enhancing safety with potassium phosphates injection. Dynamics. 2007 Jan;18(4):34-36.
(16) Hemstreet BA, Stolpman N, Badesch DB, May SK, McCollum M. Potassium and phosphorus repletion in hospitalized patients: implications for clinical practice and the potential use of healthcare information technology to improve prescribing and patient safety. Curr Med Res Opin. 2006 Dec;22(12):2449-2455.
(17) Cohen MR. Safe practices for compounding of parenteral nutrition. jpen -Parenter Enter. 2012 Mar;36(Suppl 2):14-19.
(18) Miron D, Tiosano T, Blondheim O, Sorozkin A, Moalem M, Goldstein L et al. “Concentrated kcl-free” hospital: stopping the use of potassium chloride concentrated ampoules in clinical departments and units-steps in implementing a new policy for increasing safety of drug the rapy. Harefuah. 2007 Sep;146(9):650-652, 736.
(19) Bonvin A, Vantard N, Charpiat B, Pral N, Leboucher G, Philip F et al. Accidental intravenous injection of potassium chloride: analysis of contributing factors and barriers to risk reduction. Ann Fr Anesth Reanim. 2009 May;28(5):436-441.
(20) United States Pharmacopeial Convention. usp pharmacists’ pharmacopeia 2008-2009. Rockville, MD: United States harmacopeial
Convention; 2008.
(21) Trissel LA. Handbook on injectable drugs. 17th ed. Bethesda, md: American Society of Health-System Pharmacists; 2012.
(22) Brady AM, Malone AM, Fleming S. A literature review of the individual and systems factors that contribute to medication errors in nursing practice. J Nurs Manage. 2009 Sep;17(6):679-697.
(23) Wright K. Do calculation errors by nurses cause medication errors in clinical practice? A literature review. Nurs Educ Today; 2010
Jan;30(1):85-97.
(24) Barras M, Moore D, Pocock D, Sweedman M, Wilkinson C, Taylor K et al. Reducing the risk of harm from intravenous potassium: a multi-factorial approach in the haematology setting. J Oncol Pharm Pract. 2014 Oct;20(5):323-331.
(25) Van de Vreede MA, Wilson SG, Dooley MJ. Intravenous potassium chloride prescribing and administration practices in Victoria: an observational study. Med J Australia. 2008 Nov 17;189(10):575-577.
(26) Rosselli D, Calderón C, Calderón T. Los medicamentos premezclados y su papel en la seguridad de las unidades de cuidado intensivo. Via Salud. 2008;(45):21-26.
(27) Shekelle PG, Pronovost PJ, Wachter RM, McDonald KM, Schoelles K, Dy SM et al. The top patient safety strategies that can be encouraged for adoption now. Ann Intern Med. 2013 Mar;158(5):365-368.
(28) Ucha M, Martínez N, Troncoso A, Campelo E, Vázquez C, Inaraja MT. Pharmaceutical care strategies to prevent medical errors. Rev CalidAsist. 2009 Aug;24(4):149-154.
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