Don’t lose your concentration

By Amy Rosenberg, Pharm.D. and Gale Danek, Ph.D., R.N.

A misunderstanding of medication concentration was a common reason for serious errors last year. One patient receiving continuous infusion phenylephrine needed a more concentrated solution. An overdose occurred when the new, more concentrated bag was inadvertently administered using the same mL/hr rate as the previous (less concentrated) bag. For another patient, a misunderstanding of an epinephrine vial’s concentration resulted in an overdose. In two other instances, a misunderstanding of a morphine vial’s concentration led to morphine overdoses.

What systems improvements were made?

Concentration is included along with medication name in large font on continuous infusion labels prepared by the pharmacy.

The storage locations for concentrated forms of target high-alert medications has been further restricted.We continue to abide by our standard concentration policy.

What can you do?

Always verify the concentration of any medication before administration. Although we use standard concentrations for most medications, there is more than one standard concentration for many of these. Also, manufacturer packaging (vials/syringes) may look identical even when concentrations differ.

Let the Alaris pump help you. Use guardrail programming and verify the concentration selected matches the concentration of the bag to be infused.