Description of Event or Problem · 1
THE IMPLEMENTATION OF THE NEW BD SIMPLIST SYRINGES DURING DRUG SHORTAGES HAS LED TO ERRORS IN OUR HOSP. PREVIOUSLY WITH HYDROMORPHONE PREFILLED SYRINGES AND NOW WITH DIPHENHYDRAMINE PREFILLED SYRINGES. THE PLUNGER OF THE SIMPLIST SYRINGE MUST HAVE PRESSURE MAINTAINED BY THE ADMINISTERING PERSON THROUGHOUT THE ADMINISTRATION. IF PRESSURE IS NOT KEPT ON THE SYRINGE, THE PLUNGER CAN POP OUT THUS SPRAYING OR LEAKING DRUG. AFTER CONTACTING THE MFR, THEIR RESPONSE WAS AN INFOGRAPHIC EXPLAINING THAT PRESSURE MUST ALWAYS BE KEPT ON THE SYRINGE. THE CONCERN IS THE MEDICATIONS BEING ADMINISTERED THROUGH THESE SYRINGES ARE SOMETIMES GIVEN VIA SLOW PUSHES OVER 5-15 MINS. NURSES WILL OFTEN COMPLETE OTHER SMALL TASKS AND PUSH A SMALL AMOUNT AT A TIME, NOT MAINTAINING CONSTANT PRESSURE. IF THIS OCCURS, THERE IS A HIGH RISK OF THE PLUNGER POPPING OUT OF THE SYRINGE AND ERRORS OCCURRING. SEVERITY: CIRCUMSTANCES OR EVENTS HAVE CAPACITY TO CAUSE ERROR. (B)(6).