【持续性肾脏替代治疗CRRT英文精品课件】CRRT Complications and Troubleshooting.pptVIP

Objectives At the end of this presentation, the health care provider will be able to: List the potential errors associated with pharmacy prepared solutions Review actual errors associated with CRRT solutions that have occurred in different institutions Apply the information to a case study Potential for Errors in CRRT Physician errors when using non standard orders for dialysate or replacement solutions Nursing administration errors in choice of solutions Pharmacy transcription errors in dialysate orders Pharmacy calculation errors in compounding Pharmacy product selection errors in compounding Administration Errors Confusion of calcium chloride infusion bags for sodium bicarbonate replacement solution bags Labeling of calcium chloride infusion bags with bright fluorescent stickers by pharmacy Separation of replacement fluids from calcium chloride bags in separate bins Administration Errors Nursing mixed concentrated Normocarb dialysate with normal saline instead of sterile water Pharmacy mixing of Normocarb? Dialysate Compounding Errors Foothills Medical Centre, Calgary Health Region 83 yo female in CV ICU died suddenly in the presence of family and physicians ICU physician suspected dialysate used for CRRT An analysis of dialysate solutions revealed potassium chloride was used in place of sodium chloride Attributed to another death that occurred one week prior Foothills Medical Centre, CHR 3 liter bags prepared in batches of 36 bags Dialysate concn Na 110 mEq/L, Mg 0.7 mEq/L Prepared by 4 pharmacy technicians involved in setup and documentation, checking of setup, product transfer, final check No empty bottle verification against worksheet No pharmacist check of final product Foothills Medical Centre, CHR At FMC, 34% of the pharmacy staff were pharmacists National averages are 44% pharmacists “Tech check tech” delegation endorsed by CSHP Over delegation of pharmacist responsibilities? CHR Recommendations “The feasibility of using commercially prepared dialy