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Identified patient-safety risks associated with manipulation must be mitigated as far as reasonably possible.

Strategies

Purchasing for Safety

Pharmacy teams can help to mitigate risks through their purchasing strategy. Avoid purchase of high-risk products if possible but be aware that lack of market choice is making it increasingly difficult to do this. See  Purchasing for safety (SPS page)

Use ready-to-administer products where possible

When licensed ready-to-administer products are unavailable, make available unlicensed ready-to-administer or ready-to-use injectable products where possible.

When the risk assessment tool has identified that risk reduction measures are required, consideration should be given to mitigation measures. Examples are provided below.

Examples of other risk mitigation measures

This list is not exhaustive.

Simplify and rationalise stock

Simplify and rationalise as far as possible the range of products and presentations of injectable medicines stocked in clinical areas and keep only the most appropriate vial/ampoule sizes.

Maintain awareness of look-alike and sound-alike errors

Be aware that some clinicians believe that ready-to-use preparations increase the risk of look-alike errors.

Provide aids such as dose calculators

To minimise the need for dose calculations, consider providing aids such as a dosage chart for a range of body weights.

Provide additional written guidance

Provide additional written guidance such, as clinical area worksheets, on how to prescribe, prepare and administer high-risk injectable medicines

Provide locally-approved protocols

Provide locally approved protocols that detail when unlicensed and ‘off-label’ use of injectable medicines is supported by local medicines policy

Encourage use of infusion monitoring forms

Encourage use of an infusion monitoring form to help ensure that infusions are monitored throughout administration

Consider the value of in-process checks

Consider introducing systems such as independent second checks of key steps in preparation by another experienced practitioner.

Consider use of “Smart” infusion devices

These devices can be set up and validated to only allow administration within approved parameters and therefore, if used properly by staff trained in their use, can provide a hard barrier which will minimize the likelihood of errors.