I saw a brief from the ASHP Section of Inpatient Care Practitioners about invasive Staphylocuccus aureus ourbreaks from reuse of single-dose vials. Close inspection of the CDC report shows that the problem in one case was a matter of the clinic staff repackaging sterile medications for later use (all the infections came from a vial prepared in the morning for use in the afternoon) and another where the user preparing the injections had nasal colonization of the offending strain of S aureus. In both cases, one excuse for the behavior was the limited availability of the agent in question.
The report highlighted a few things for me:
- The medication-use process in health systems is broader than we often think about it, and there are things going on in procedural areas of which we are often not aware. One wonders what might have been different if these areas had invovled their pharmacy in the solution to the product availability problems.
- Well-meant intentions do not necessarily results in good outcomes. Healthcare providers do not set out intending to harm patients, but may often do things without thinking of long-term consequences.
- There is a reason why we have USP <797> and why it needs to be understood beyond the walls of the pharmacy. There seems to be a pervasive impression among healthcare providers that their techniques and facilities are sufficient to produce sterile doses, however poor they may actually be.
Certainly, nobody in either case set out to harm patients. Likely the individuals in both cases perceived the need to keep the doses sterile and the need to manage cost associated with a shortage as issues of equivalent value.
One finds oneself wondering what knowledge or involvement a health-system pharmacy could have had in these episodes; one wants to believe that such involvement could have made a difference.
In any event, these events highlighted to me the need for us to have a much broader view of the medication-use process within our health systems, and to take a more proactive stance in managing all of it.
They also reminded me that, however our clinical role evolves, we still have a responsibility to ensure the safety of the entire medication-use process, not just the clinical application of drugs.
Just one man's opinion. What do you think?
Dennis A. Tribble, Pharm. D., FASHP
DATDoc@aol.com
(386) 871-6940
The opinions expressed in this blog are my own, and not those of my employer or of the American Society of Health-System Pharmacists.
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