Supply interruptions in intravenous antimicrobials rarely announce themselves as safety events. The bag is simply not there, a substitute appears, and the preparation step that had been engineered out of the process quietly returns. Nobody documents the change, and the first sign of trouble is a reaction or a subtherapeutic level.
Build the habit of treating any antimicrobial presentation change as a clinical change, not a procurement one. When a formulation switches, write down what changed, what the new concentration is, what the new maximum rate is, and who has been told. The five minutes spent doing that is the difference between a supply problem and an incident report.
- Treat a formulation or presentation switch as a clinical change requiring a briefing, not a stock note.
- Record the new concentration and maximum infusion rate in writing at the point of preparation.
- Check compatibility with existing giving sets and co-infusions before the first dose.
- Ask explicitly whether therapeutic drug monitoring timing is affected by the new preparation.
- Tell night staff directly; they are most likely to meet the substitute first and least likely to have been told.
Why it matters
Presentation changes bypass every safety process built around prescribing, because nothing about the prescription changes.
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