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Refrigerated Medications at Risk for Errors
Vol. No: 28:09 Posted: 9/15/03
Refrigerated Medications at Risk for Errors


John P. Santell, MS, RPh
Diane Cousins, RPh

There are many drug products that require refrigeration, and refrigerators are used throughout the hospital by both pharmacy and nursing personnel. During the past three years, USP's MEDMARX medication error reporting program has received nearly 1,000 reports involving refrigerated medications. USP has been able to identify several "chilling" themes regarding the use of a refrigerator to store medications:

Accessibility and poor storage: Easy access to products that are poorly or improperly stored in a refrigerator creates the risk of drug mix-ups. Multiple types and strengths of vaccines, insulins, and antibiotics that are readily available in common storage bins or drawers within the refrigerator have led to numerous wrong-drug and wrong-dose errors. Possible solution: An adequate number of clearly labeled storage bins should be used to separate different products and different strengths. Consider obtaining a larger refrigerator that will accommodate the unique needs of a particular patient care area.

Products with similar packaging and labeling: Given the storage space limitations of refrigerators, there is an increased potential to confuse similar-looking packages and labels. Possible solution: Devise a system that eliminates or minimizes all look-alike products within a refrigerator. Consider keeping all patient-specific insulin vials in the patient's medication drawer rather than storing the vials in the refrigerator. Conduct an inventory of the types of products stored in the facility's refrigerators. Request that the Pharmacy and Therapeutics Committee, or other appropriate safety committee, review this inventory of commonly stored products to identify look-alike pairs and evaluate where and how to eliminate these potential mix-ups.

Nursing staff unaware of medications requiring refrigeration: The majority of medications nurses receive from the pharmacy and eventually administer to patients are not stored inside a refrigerator. Therefore, they do not immediately think of looking in the medication refrigerator when tracking down a drug to administer at a scheduled time. In these instances, patients either get the drug much later than was originally scheduled or, even worse, not at all. Possible solution: Methods to alert and remind nursing staff of medications stocked in refrigerators should be developed (eg, a chart or table can be displayed on the outside of the refrigerator door listing the most common refrigerated items for that particular unit). Also, the lack of knowledge regarding which medications require refrigeration leads to the disposal of drugs that have been left unrefrigerated or to the administration of drugs that have become unstable or less potent because of improper storage.

Typical examples of drug errors associated with refrigerators are reported in this article.

Case Examples of Errors Involving Refrigeration
Accessibility and Poor Storage:

Case #1: Because of space limitations, different strengths of cephazolin IV piggybacks were placed in the same bin within the refrigerator located on a particular nursing unit. A patient had been on 1 g IV every eight hours but dosage was recently decreased to 500 mg every eight hours. When it was time to administer the next dose, the nurse inadvertently retrieved a 1-g IV bag labeled with the patient's name instead of a 500-mg bag.

Case #2: The pharmacy dispenses Epogen vials with patient-specific labeling including a "keep refrigerated" label on the zip-lock bag. However, once the initial dose is administered to the patient, the vials are generally not returned to the zip-lock bag containing the reminder label. Consequently, many vials are left in the patient's medication drawer instead of being returned to their appropriate storage environment. In these situations, the length of time that the vial has been outside the refrigerator is difficult to determine and, therefore, the product must be discarded because the medication's potency is in question.

Case #3: Patient "A" had been receiving an IV piggyback of ampicillin/sulbactam but the order was discontinued. However, the piggyback IV bags for that patient were not removed from the refrigerator during the course of one eight-hour shift. Patient "B" was in the same room as Patient "A" and was receiving cefazolin IV piggyback. A nurse who intended to retrieve cefazolin from the refrigerator mistakenly retrieved one of the ampicillin/sulbactam piggybacks instead and administered that product to Patient "B."

Products With Similar Packaging and Labeling:

Case #4: Various types of Insulin were stored in the same section of the refrigerator (known as the "egg bin" in a home refrigerator). Patient-specific vials were not dispensed from pharmacy; rather individual insulin doses were withdrawn from floor stock vials. A patient was ordered Humalog Mix 75/25 but instead received Humalin 70/30.

Case #5: A registered nurse who was looking for heparin 1,000 units/cc to be used for a line flush found five vials of heparin 10,000 units/cc in stock in the unit's medication refrigerator. The nurse discovered one vial that had already been opened and proceeded to withdraw from this vial. There was a potential that many patients had received an overdose if this concentrated vial was being used for line flushes, but there was not sufficient documentation to determine if an incorrect calculation had occurred. The nursing unit's policy is that only heparin 1,000 units/cc is to be in stock.

  Nursing Staff Unaware of Medications Requiring Refrigeration:

Case #6: Four liters of Golytely were ordered to be given to a patient over a two-hour period. The first two liters were given to the patient by the day-shift nursing staff. However, the day nurses failed to inform the evening shift that the remaining two liters of Golytely were being stored in the refrigerator. Approximately three hours past the scheduled administration time, the remaining two liters were found in the refrigerator. The physician was informed of the complications related to the administration of the Golytely and made a decision to delay the patient's surgery. 

Case #7: An IV bag of total parenteral nutrition (TPN) solution that was being infused into a patient was nearly empty and the next bag needed to be hung. However, the floor nurse could not locate the next scheduled dose in the unit's medication room and she could not request another bag to be compounded since the pharmacy was already closed for the evening. The nurse temporarily stopped the TPN and started the patient on D10W until a dose could be compounded and dispensed by the pharmacy. Upon delivery of the replacement TPN the following morning, the pharmacy technician discovered that the "missing" TPN was actually in the unit's medication refrigerator, but the evening shift was unaware that that is where TPNs were stored. Because of the interruption in the TPN regimen, extra lab tests were ordered to ascertain the patient's electrolyte levels. 

Case #8: Zithromax was ordered on Day #1 at 07:00 am, but nursing staff could not locate the item and circled 11:00 am on the medication administration record (MAR) as drug not available and therefore, not given. The patient did not receive the antibiotic for 24 hours. On Day #2, the nursing staff discovered two bags of Zithromax for this patient in the refrigerator that were marked with the date for Day #1. The patient was very discouraged upon learning that administration of his antibiotic had been delayed for so long given his history of a heart transplant and battle with osteomyelitis of the mandibular bone. The patient had to be re-evaluated and upon review of the chest x-ray, it was found that there was infiltrate in the left lower lung. 

Case #9: A patient was ordered 288 mL of magnesium citrate for bowel cleansing to begin at 3:00 pm. Late into the evening shift, a nurse who was monitoring the patient noted that the patient had not yet had a bowel movement and, in addition, the patient's abdomen was distended. A review of the original orders compared to the nursing MAR revealed that the magnesium citrate had never been administered. Further investigation revealed that the day-shift staff had not realized that the magnesium citrate for this patient had been placed in the refrigerator and, because of the heavy patient census, forgot to follow-up in either locating the product or requesting a replacement. The drug was found in the refrigerator where it had been placed one hour before the scheduled administration time. Because of the delay, the patient experienced prolonged constipation and a distended abdomen through the next day.


Vol. No: 28:09 Posted: 9/15/03

December 2008
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