Fake and expired medications in simulation-based education: an underappreciated risk to patient safety

Introduction In January 2015, the US Food and Drug Administration (FDA) reported that at least 40 patients had received non-sterile intravenous fluids, resulting in associated adverse events and one death. The offending products were produced for educational purposes by a company supplying the growing healthcare simulation market, and were not intended for patients. The plastic bags, labelled to mimic sterile 0.9% saline solution, contaminated the medication supply chain in 22 locations.1 Although the sequence of events is not yet clear, the supply shortage of 0.9% saline in the USA2 may have been a contributory factor. The presence of fake products was a latent condition or ‘resident pathogen’3 which in certain circumstances led to error and patient harm. Harbingers of the tragic events above have been reported, such as the discovery of demonstration adrenaline syringes on an emergency trolley for clinical use and...

Source: BMJ Quality and Safety - November 17, 2016 Category: Journals (General) Authors: Torrie, J., Cumin, D., Sheridan, J., Merry, A. F. Tags: Viewpoints Source Type: research