Arkansas Board of Pharmacy responds
Mood:
on fire
Dr. DeCoster, I have received statements from both pharmacist evolved in the incident you reported. The order was entered by a pharmacy technician and upon verification by a pharmacist the label was generated indicating the dosage of "0.1 unit (0.001ml) Sub Q now" The Insulin was sent to the NICU with this label. The pharmacist did not question the fact that the dosage would require a dilution to be made on the floor by the nursing staff since they were allowed to make dilutions and the dosage is checked by another nurse. There was no direct communication between the pharmacy staff and the nurse that gave the dose or the nurse that checked the dose. That is one place where the system must be approved for the administration of all medications. The pharmacy policy has been revised (9/28/05) to make the dilution in the pharmacy to such a volume that can be measured by the nursing staff (without dilution on the floor) for administration. The responsibilities of each pharmacist represented in this incident have been presented with the new policy and what is required of them in further situations. The whole pharmacy staff has been in serviced regarding changes and requirements that have resulted from this very serious situation that resulted in a very serious medication error. The procedure to allow or require the nursing staff to make dilutions with a high risk medication is unacceptable, and with the change in procedure and protocols it should not happen again.
This reported incident and policy and procedure changes will become a part of the hospital pharmacy file and each pharmacist file.
The pharmacy along with pharmacist evolved have been warned.
Please feel free to contact me regarding this investigation.
Ron Ewing, P.D.
Inspector
Arkansas State Board of Pharmacy
101 E. Capitol Suite 218
Little Rock, AR 72201
Phone: (501)682-0196
Fax: (501) 682-0195
ron.ewing@arkansas.gov
Posted by drdecoster
at 1:12 PM CDT
Mama?s 5th entry?
Last Thursday Nevin said, “I wish my baby brother had been born bigger. Then he could have come home the same day.” If all continues to go well, Kent will come home Friday.
We are doing more and more breast feeding. He now is doing some breast feeding back to back to build his endurance. Wednesday I room with him for 24 hours, Vaughn will be bringing me some decent food. We’ve had some rate of flow issues, where he wanted Mama to work like the pacifier and the tube to his stomach so I’m not ready for him to have any bottle feeds.
Kent is often very alert and he stares at our faces and objects in the room. He dislikes loud noises and he likes to snuggle.
He is off all meds. No apnea problems. We just make the alarms sound, when we disengage his monitors while feeding.
The final count down is on. Vaughn and I take an infant CPR class Tuesday. Kent has to pass a stress test by sitting in his car seat for 30 minutes (I think) and his eye exam is Tuesday. He passed his hearing test last week. Thursday he’ll be circumcised.
Thank you for the prayers and please keep them coming.
Posted by drdecoster
at 11:53 AM CDT
Posted by drdecoster
at 5:49 PM CST
bright
a-ok
