Safer administration of medicines

The administration of medicines or substances by the wrong route, including intrathecal and epidural, and the accidental injection of chlorhexidine, make up a small but serious proportion of the problem of injection errors in medicines administration.

Safety statement on metered dose inhalers

The Australian Commission on Safety and Quality in Health Care (the Commission) recommends metered dose inhalers and other metered dose products continue to be prescribed and labelled by the metered dose. The Commission recommends:

  • Prescribing and communicating by the metered dose
  • Labelling with the displayed metered dose. The delivered dose may also be displayed if defined with clear description, such as ‘each inhalation contains a metered dose of (X micrograms) which is equivalent to a delivered dose of (Y micrograms)’
  • Consumers understand how to use their inhaler correctly to ensure a complete dose is delivered to the site of action
  • Electronic medication management systems are configured to describe the doses consistently between systems for all purposes including prescribing, dispensing administration and reporting.

View the statement:

Topical application of chlorhexidine and the risks of accidental injection

A joint safety statement was developed in response to reported incidents of accidental injection of chlorhexidine. Typically, the accidental injections are associated with drawing up chlorhexidine from gallipots, rather than following national anaesthetic and user-applied labelling guidelines and standards.

The statement includes recommendations consistent with the National standard for user-applied labelling of injectable medicines, fluids and lines and ANZCA’s PS51 Guidelines for the Safe Management and Use of Medications in Anaesthesia, including the use of dark-tinted chlorhexidine for skin preparation is advocated, as light-tinted chlorhexidine increases the risk of errors.

Neuraxial connectors and ISO 80369-6:2016

Internationally, safety organisations have tried to reduce the incidence of erroneous injection with education of health personnel, storage, and colouring and labelling of medicines and devices, including the National standard for user-applied labelling of injectable medicines fluids and lines.

The International Standard ISO 80369-6:2016 Small bore connectors for liquids and gases in healthcare applications – Part 6: Connectors for neuraxial applications was introduced with the aim of reducing the injection of erroneous substances via intrathecal, epidural and other neural routes. ISO 80369-6:2016 specifies the design and dimensions of small-bore connectors intended for all neural applications, including neuraxial, peripheral and regional applications.

In a joint statement, the Australian and New Zealand College of Anaesthetists (ANZCA) and the Commission recommend that ISO 80369-6:2016 be adopted in Australia as part of a global initiative to improve patient safety.