Forcing functions to reduce risk with metaraminol use at Austin Health

Abstract

Aim An in-depth review of an error involving the inadvertent administration of a twenty-fold higher dose of metaraminol, due in part to the presence of two metaraminol product concentrations (10 mg/1 mL vials and 3 mg/6 mL vials), recommended keeping a single concentration in operating theatres. Using forcing functions such as removing concentrated solutions associated with risk is a more effective systems-focused intervention when compared with education and training alone.1 To learn from medication incidents for system wide improvement, this study aimed to implement a single concentration of metaraminol throughout the organisation, to reduce the risk of future medication errors. Methods The feasibility of complete removal of the 10 mg/1 mL metaraminol product from Austin Health was tested in partnership with clinicians to ensure viability of a product switch. Alternative products were assessed for quality of packaging and labelling, product availability with secured supply chains, budget impacts and potential wastage. Working closely with the Cerner Electronic Medical Records (EMR) team, the intravenous order sets that display in the EMR were revised. These were crucial to ensure the prescribing and documentation would be clear and unambiguous on changeover day. A one-page summary was published on the hospital intranet, together with signage and focussed communication to medical, nursing and pharmacy staff. Results Prior to changeover day in October 2023, Austin Health had two concentrations of metaraminol in operating theatres, recovery, emergency, intensive care unit and selected procedural areas. The 10 mg/1 mL vials have been removed and replaced with a pre-diluted vial containing 10 mg/ 20 mL. The changes were made in Cerner EMR and infusion orders monitored to ensure a smooth and safe transition. Conclusion Implementation of recommendations from incident reviews may protect consumers and clinicians from administration errors related to wrong product selection. 1. Soong C, Shojania KG. BMJ Qual Saf 2020; 29: 353-357