I s s ue 1 5 – O c tob er 2015

What’s new? NovoRapid® FlexPen®

In July, we published a factsheet, Making

strong opioids safer for patients. This links
closely to our high-risk medicines topic in
NovoMix® 30 FlexPen®
Medication Safety Watch the Open for better care campaign and
the work of the collaborative.
A bulletin for all health
professionals and health care Update on the collaborative
managers working with medicines A very successful learning session two for The following system changes will reduce
or patient safety. the collaborative was held on 23 and the risk of incidents involving look-alike,
Key messages 24 June 2015. The DHB teams are now sound-alike insulin products.
• Improving vaccine safety working hard to implement their proposed
• Safe use of opioids national • Display a chart showing all available
interventions using plan-do-study-act
collaborative insulin products in the dispensary/drug
(PDSA) cycles.
• Incidents and cautions room.
Contact details: The first in a series of webinars hosted
• Store products with look-alike names
beth.loe@hqsc.govt.nz by the Commission and the Institute for
Ph: +64 9 580 9160 and/or packaging separately in the
Healthcare Improvement was held on
fridge.
Medication alerts and 22 September 2015 for collaborative
teams and focused on completion and • Check the patient’s dispensing
safety signals documentation of PDSA cycles. history when entering a new insulin
These alerts and safety signals prescription before selecting an item to
The second edition of the collaborative
provide information and actions dispense.
about high-risk medicines and newsletter has also been published.
situations. They are issued to • If possible, check with the patient/
health care staff, managers Incidents and cautions family/whanau/carer that the product
and organisations. For more you are dispensing or administering is
Clozapine
information, contact Beth Loe. the one they were using previously.
Metoprolol alert Cases of myocarditis associated with
clozapine have been reported and Inhaler brand confusion
The Health Quality & Safety
resulted in coronial inquiries. Clozapine- Several cases have been reported where
Commission has received signed
action plans from 15 district health related adverse reactions and monitoring Beclazone® inhalers were dispensed
boards (DHBs) (75 percent). requirements featured in the June when QVAR® inhalers were prescribed.
These will inform our future work Prescriber Update. Prescribers should specify the brand
on metoprolol. We will ask the when prescribing beclometasone inhalers
remaining five DHBs to complete NovoRapid® FlexPen® and
because of the different characteristics
and return their action plans. NovoMix® 30 FlexPen® wrong
and recommended doses of Betazone®
This Safety Signal: Risk of product dispensing and
and QVAR®. When dispensing beclo-
serious adverse drug administration incidents
metasone inhalers, dispense the brand
reactions was released on 30 The commonest incident reported to the specified on the prescription, or check
September, and follows the fatal Medication Error Reporting Programme
administration of trimethoprim to a with the prescriber which brand is
(MERP) involving these products is intended.
patient with a known, documented
NovoMix® 30 FlexPen® being dispensed
allergy to trimethoprim, and who Missing fentanyl patch harms child
was also wearing a MedicAlert® instead of NovoRapid® FlexPen®. There
bracelet. has also been a report where NovoRapid® An incident in May 2015 reinforces
UPCOMING: The safe use of FlexPen® was administered in an aged the need for proper disposal of fentanyl
opioids collaborative final learning care facility instead of NovoMix® 30 patches to prevent accidental exposure
session for DHB team members FlexPen®. The products look similar, in children. In this case, a fentanyl patch
and associated stakeholders will especially when the outer packaging has fell off and wasn’t found by adults. Later,
be held on 10 and 11 November been removed, the pens are in a facility a 14-month-old was found choking;
2015 in Auckland. fridge and staff are unfamiliar with the the mother checked for objects in the
variety of pens available. cont. on page 3

The information in this bulletin is believed to be true and accurate. It is issued on the understanding that it is the best available information at the time of issue. 1
 Medication Safety Watch

Reducing vaccine incidents

As with all medicines, adverse incidents involving vaccines can occur. New Zealand and international incident reports1 highlight
which vaccine incident types are most common. We discuss these below, with recommended system changes to reduce the risk
of those incidents happening again.
Failures in the cold chain can reduce vaccine potency or result in wastage. Medication Safety Watch previously discussed
maintenance of the cold chain and provided medication safety tips. The Immunisation Handbook 2014, the National Guidelines
for Vaccine Storage and Distribution 2012 and the Annual Cold Chain Management Guide and Record provide more information.
Other common vaccine errors
Common vaccine errors Possible causes Examples
Cold chain failures See above
Wrong vaccine Brands have similar names or packaging, or Infanrix® IPV/Infanrix® Hexa
administered contain the same antigen when the wrong product is selected
Incorrectly prepared Two component vaccines are not mixed Infanrix® Hexa when only the antigens in the
vaccines or syringe are administered without adding the
Reconstitution is required and the diluent is Hib component
administered instead of the reconstituted vaccine or
Act-HIB® when only the diluent in the syringe
is administered without the Hib component
Wrong interval between Child’s immunisation history is not up to date or Any vaccine requiring multiple doses to
doses when multiple unknown achieve full immunity
doses are required for or
immunity First dose is given after the recommended age, and
the time interval between first and second dose has
not been rescheduled so second dose given too soon
Wrong age There is an age restriction on when the vaccine RotaTeq®
should be administered or
or Varilrix®/Varivax® for paediatric use and
Age-related vaccine products exist and the wrong Zostavax® for adults aged 50+ (see latest
vaccine is administered Prescriber Update for more information)
Expired vaccines Stock rotation and human factors when picking the Any vaccine
administered vaccine for administration
or
Expiry date difficult to read
Wrong injection site Intramuscular injection to body sites without enough Any vaccine administered intramuscularly
muscle (too high on the shoulder or too far back in
the fatty tissue of the arm)
Wrong route Human factors in a busy immunisation clinic M-M-R® vaccine given intramuscularly
instead of subcutaneously
Wrong patient Human factors in a busy clinic when multiple family Any vaccine administered when siblings
members are being vaccinated at the same time present together for childhood immunisation

Strategies for preventing errors

Storage
• Store paediatric and adult formulations of vaccines in different parts of the fridge.
• If using containers to store different vaccines (in their original packaging), clearly label them.
• Store vaccines with similar names and packaging on different shelves to reduce the risk of picking errors.
• Display the batch number and expiry date label on all stored vaccines.
• Rotate stock based on expiry date to prevent wastage; put those with the shortest expiry date at the front of the fridge.
• Remove and dispose of any expired vaccines as soon as possible. A recommended disposal/destruction procedure is in the
Immunisation Handbook 2014. cont. on page 3
1 Institute for Safe Medication Practices. 2014. Confusion abounds! 2-year summary of the ISMP National Vaccine Errors Reporting Program (Part I).Horsham, PA: Institute for Safe
Medication Practices. URL: https://www.ismp.org/newsletters/acutecare/showarticle.aspx?id=95 (accessed October 2015).

The information in this bulletin is believed to be true and accurate. It is issued on the understanding that it is the best available information at the time of issue. 2
 Medication Safety Watch

cont. from page 2 When dispensing or supplying

• Have a clear process for keeping two component vaccines together or, if this tablets that are ‘for external
is not possible because one component is temperature sensitive, ensure both use only’, leave the word
components are clearly marked as needing another component. ‘tablet’ off the label. Potassium
Prescribing permanganate tablets have
• When prescribing any vaccines with look-alike generic names, specify the been given orally because of
brand name too.
confusion caused by the word
• Highlight the administration route.
‘tablet’ on the label.
• Verify the patient’s current immunisation status from health records and the
National Immunisation Register (NIR), in the case of a child.
• For frequently administered vaccines, establish order sets/quick lists/protocols cont. from page 1
in electronic systems that include:
–– the full generic name, brand name (if applicable) and standard abbreviation child’s mouth but found nothing. An
ambulance was called and the child
–– directions (eg, the route), and any special procedures to improve safety
developed stridor. When ambulance
–– information on required follow-up doses
staff arrived, they found a fentanyl
–– details about what (eg, batch number, expiry date) and where (eg, NIR, patch stuck to the roof of the child’s
vaccination record) to document administration. mouth. The child became hypoxic and
Prescribing and administration had seizure-like activity on the way to
• Differentiate the appearance of similar vaccine names on computer screens by hospital. Despite two bolus doses of
highlighting dissimilarities and including full product and brand names. naloxone in the emergency department,
• Verify the patient’s age by asking for their birth date (if the patient is available the child’s respiratory rate declined and
or their family/whanau/carer) and referencing the health/immunisation an infusion had to be started. The child
record before prescribing, dispensing or administering a vaccine. needed intensive care admission and a
Administration naloxone infusion overnight.
• Only reconstitute vaccines using the diluent supplied by the manufacturer.
Cases, some fatal, involving children
• Clearly label or distinguish diluents (highlight or circle that part of the label) finding and applying fentanyl patches
if the manufacturer’s label could mislead staff into believing the diluent is the
found in rubbish bins have been
vaccine itself.
reported previously.
• If multiple children are being seen at the same time for vaccination in a clinic:
–– structure appointments so one child at a time is seen This case highlights the importance of
giving all fentanyl patch users advice
–– if more than one child is being seen at the same time, only bring one child’s
vaccines into the room at a time about safe use and disposal. The child’s
mother had no idea her lost patch would
–– check the child’s identity using two identifiers (eg, name and birth date)
before administering each vaccine. be found and harm her child. Some
patches stick poorly and information
• If a quick reference guide is available, post one for clinicians to verify the
on how to secure them could have
administration route for all vaccines.
prevented this incident.
• When administering two-component vaccines, document the batch number
and expiry date of each vial in the vaccination record before administration to
confirm correct selection or preparation of both components. Document actual Upcoming events
administration after the vaccine has been given. • 8th Medication Safety Conference
• Involve the patient/family/whanau/carer in the verification process. 2015. Abu Dhabi, 6–8
Help us learn more about problems with administering vaccines and improve November 2015. See www.
systems by reporting any vaccine errors and near misses to MERP. medicationsafetyconference.com for
You can contact the Immunisation Advisory Centre on 0800 IMMUNE for advice more information.
if an incident occurs.
• IHI 27th Annual National Forum.
NB: Remind parents/families/whanau/carers that fever in young children Orlando, 6–9 December 2015.
may occur after vaccination but prophylactic use of an analgesic/antipyretic See www.ihi.org/education/
medicine, such as paracetamol, before or at the time of vaccination is not
Conferences/Forum2015/Pages/
recommended. Refer to the Immunisation Advisory Centre’s position statement
on the use of paracetamol around the time of immunisation. Overview.aspx for more information.

www.hqsc.govt.nz

The information in this bulletin is believed to be true and accurate. It is issued on the understanding that it is the best available information at the time of issue. 3