Passing meds in the OR

[RockieSis]

After the airing of the Dateline program this fall re: the mix up of medications that cost a small child his life during a routine pediatric procedure in the OR, our OR supervisor asked several of us to write a new policy and procedure for this. It will set the procedure for the way medications are dispensed onto the back table during surgery. We currently follow the routine shown in the program of pouring meds into labeled med. cups. If someone in the reading audience has a P/P on this I would be forever grateful if you would share it with me to use as a guide as we draft our own.

thanks

RockieSis

[P_RN, ADN, RN]

I didn't see the Dateline, but I did read the transcript on MSNBC.

That was so tragic.

P

[MickeymomRN]

Interesting. One of my Surg Tech students brought in that episode. It brought out a real good discussion on how to eliminate that error. Even though the cups are labeled. I believe the syringes used to draw up the meds weren't. And I've seen RNs pass meds without having the Tech actually look at what they are pouring out. IE. confirm that they poured the adrenaline into the cup that was labeled for it. I know we were taught to just pour out the meds from the original container into another that was labeled. And I know that usually Techs aren't taught Pharmacology. I believe that if they were they'd be more vigilant about handling the meds that pass through their hands. True, RNs are the ones responsible but there's room for error after the meds are passed to the "middle" man ( the Tech). Sorry I couldn't help with finding a p&p for you but hopefully this will teach us to be more careful in the field.

[mud]

We don't have a P&P for this either. We are however, extremely careful with meds in the field. We will use sterile martkers to mark things if there is any chance of a mix-up, also using differnt syringe sizes for different meds. We all say aloud the drug wanted, read the label aloud, with the expiration date. The only time we ever have adrenalin 1:1000, is for one of our ENT docs. We do not bring it in the room until he asks for it, then we pour it for him, and after it is used, it is removed.

Sorry I could not be of more help.

[passionate]

AORN standards, recommended practices and guidelines addressess this. If your instituion does not have a pp then AORN is the standard by which your practice will be judged.

[bifurcated]

to MickymomRN...... tech's are not taught pharmacology true. However the RN is! Our policy has always been that the RN delivering the drug to the scrub (rn or tech) shows the drug states what it is shows the expiration and then the scrub states it back to the circulator. Mistakes happen when people get in a hurry and do not do the appropriate steps. Like LABELING THE SYRINGES ALSO! JACHO would have you guys fined for not doing that. We all need to be especially careful with pediatrics because the doses (unless you work nothing but peds) are so different. so label everything you have and label it correctly...... take the time to do it right.

[passionate]

We label any drug on the backtable and this includes NaCl and H2O

[zerby1470]

The tech students from the school in my area are required to take pharm, and pass prior to entering the OR for clinical. If you don't know the risks and benefits of what you are using, be it a med, ESU, or anything else, it is difficult to use it safely. I am dissapointed that this isn't the norm.

[passionate]

What saddens me is the it takes a tv program to point out what has been a standard practice for a very long time. We have a collective concience--The AORN standards reinforce that every year.

[ewattsjt]

the surgical technology students here are taught pharmacology. in fact, the nursing asn and surgical technology aas students take the same pharmacology classes. it is amazing that it isn't a standard across the country.

it kills me to hear a surgical technologist say, “i don’t need to know what it does; only that the doc wants it”. it is that attitude that creates an environment that allows for errors. if the techs have an idea of the drug, they may be more vigilant to label, follow the “five rs”, etc… and ask questions.

i guess what i am saying is that i do not understand how someone who can pass potentially lethal meds, does not have to have had a pharmacology class.

[elcue]

quote:i guess what i am saying is that i do not understand how someone who can pass potentially lethal meds, does not have to have had a pharmacology class.

agreed. what is truly frightening is what medical assistants with very scant training do in docs' offices - giving meds, innoculations, etc - , all in the name of $$ - hiring the cheapest help available. appalling. and sop in this country, in this day.