Patient safety alert: Restricted use of open systems for injectable medication

This alert requires organisations to revise policies and establish systems of audit to ensure an “open system” is not used as a container for injectable medication (with the exception of embolic agents for embolization procedures).

This practice risks one medication being confused with another, and medication intended for injection being confused with other substances.  Additionally, an ‘open system’ can become contaminated by bacteria.

 

In 2007 the NPSA issued the alert “Promoting safer use of injectable medications”. This stipulated that injectable medicines must be drawn directly from their original ampoule or container into syringes, and then either administered immediately or, if they are not for immediate use, the syringe is labelled and checked before later use.  Despite this, the use of open systems has continued in some organisations and specialities.  Reports suggest this typically occurred during procedures where repeated injections may be required, such as for the use of anaesthetic and anticoagulant agents.