Could this happen at your facility?

As seen in the Consultant Connection March 2016 Issue
Long-Term Care Advise ERR January 2016 
Safety-Wire-Icon-small-(1).jpg  A used oxymetazoline nasal spray was inadvertently placed back in storage with unused oxymetazoline nasal sprays for house stock. The used product was almost administered to the wrong person. The error was identified when the cap was opened and blood residue was seen on the tip of the bottle. It appears that the used spray had been initially opened by twisting off the cap but leaving the tamperresistant seal in place, then recapping it after use. A nurse or aide then restocked it in the medication room, thinking the product was unused and unopened. There is only about a millimeter of tamper-resistant seal that covers the space between the cap and the bottle. Once compromised, the entire seal should be removed, but in this case, most of it was allowed to remain.  
The organization’s medication error committee believes this incident and future incidents could be prevented by improving the product’s tamper-resistant seal and how it is placed on containers during the packaging process, so the organization sent a letter to Major Pharmaceuticals, this product‘s manufacturer. ISMP has received similar reports involving ointments and other products where blood-borne pathogens might be transmitted because a used container was mistaken as an unopened container.
ISMP would appreciate hearing about additional suggestions you might have to avoid potentially dangerous accidental product reuse. In the meantime, remind staff to completely remove the safety seal when the product is used, and to suspect a potential problem if the seal is very loose fitting over the cap, which may happen if only the bottom portion has been removed. We would also like to know what kinds of checks are made when products are returned to unit stock or the pharmacy. Please email us at: ismpinfo@ismp.org.
part-of-safety-seal-removed-w-red-line.jpg
Part of the safety seal was removed, but it mostly remains intact on the cap


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