Supply problems do not present as patient safety incidents. They present as a different box on the shelf. The prescription is unchanged, the drug name is unchanged, and every safety check built around prescribing passes - because none of them looks at concentration or preparation.
Build the habit of treating any change in presentation, concentration or manufacturer of a critical care drug as a clinical handover item. Say it at the shift board round: what has changed, what the new concentration is, what the new maximum rate is, whether the pump library has been updated, and who has not yet been told. It takes thirty seconds and it is the only point in the process where a twofold concentration change is visible to a human being.
- Add presentation and concentration changes to the shift handover, not just the stock list.
- Check the smart pump drug library has been updated before the substitute is used, not after.
- Write the new concentration at the point of preparation, not only in an email.
- Ask pharmacy for the concentration explicitly when accepting substitute stock - do not infer it from the drug name.
- Tell locum and night staff directly; they are the most likely to meet the new product cold.
Why it matters
Presentation changes slip past every prescribing safety check, because nothing about the prescription changes.
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