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Curare storage Not so uncommon mistakes

Flash sécurité patient - Posted on May 13 2022

Context

Among healthcare product-related errors from the trSAE database received by HAS from March 2017 to 31 December 2019, curare administration errors represent 11% (20/177) of all medication-related errors from the national trSAE reporting database. More than half of these errors stem from non-observance of good storage practices.


Objectives

The objectives of this focus on patient safety are:

  • To alert healthcare professionals as to the recurrence of treatment-related serious adverse events (trSAE) due to non-observance of good storage practices,
  • To raise awareness among healthcare professionals as to the absolute control of good curare preservation, storage, preparation and administration practices,
  • To reinforce acquisition of the 5 rights rule and good high-alert medicinal product administration practices,

This focus on patient safety was devised in collaboration with the drug, medical device and therapeutic innovation observatory, which makes it possible to pool tools available to professionals, while offering them the opportunity to self-asses, to assess their organisation or to train, at regional level, in liaison with the drug, medical device and therapeutic innovation observatory.


So it doesn’t happen again

This focus highlights non-observance of good curare storage practices. In effect, analysis of the deep-rooted causes and barriers reveals incorrect storage, leading to mix-ups with products with a similar pack size, along with non-observance of storage rules for these medicinal products most often sensitive to heat, the majority of them having to be stored away from light. Finally, more generally, lack of identification of curares as high-alert medicinal products, along with non-routine application of the 5 rights rule during preparation and administration completes these findings.

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