You'll see a focus on preventing dangerous diluent mix-ups when reconstituting oral powders.
In a recent case, amoxicillin suspension was prepped with an alcohol and water mixture that was sitting beside plain water.
Use the following strategies to ensure oral powders are reconstituted with the intended diluent.
Start by identifying chemical solutions in your pharmacy that you don't use regularly...or at all. Work with your admin or med safety officer to eliminate these.
For example, a pharmacy storing a formaldehyde and methanol mixture for other facilities mistakenly used it to reconstitute antibiotics...which led to patient hospitalizations.
Separate chemicals from diluents and meds...and check that chemicals have appropriate warnings.
For instance, bottles of acetic acid 0.25% or sodium hypochlorite 0.25% solutions should say "For irrigation only."
Don't reuse empty containers.
In another case, valganciclovir oral powder was reconstituted with isopropyl alcohol. The error was traced back to a bottle that previously held water...and had two different labels.
Stay alert for look-alike packaging with diluents and chemical solutions. Consider size and shape, cap and label color, etc.
Report any that you spot to your admin or med safety officer...so they can take steps to reduce error risk.
Ensure each oral powder you reconstitute is checked according to pharmacy policy...such as by showing the actual diluent container and amount BEFORE you add it to the med.
Get our technician tutorial, Mixing It Up With Medications for Reconstitution, for more safety strategies.
- ISMP Med Safety Alert! Acute Care 2021;26(6):1-5
- www.osha.gov/SLTC/etools/hospital/pharmacy/pharmacy.html (6-1-21)
- www.ismp.org/tmsbp/faq6 (6-1-21)
- www.ismp.org/guidelines/best-practices-hospitals (6-1-21)
- Technician Tutorial: Mixing it Up With Medications for Reconstitution