Image look-alike meds in Pyxis
The look-alike medications in the Pyxis machine. One is meant to be ingested by the patient to take effect, while the other needs to be swished around the patient’s mouth and then spit out. (Photo: Lisa Tinker)​

Alyzeh Pirani, a registered nurse in the Radiation Nursing Clinic at the Princess Margaret Cancer Centre, was caring for a patient who was experiencing side effects due to their radiation treatment.

The patient had been prescribed a mouthwash for mucositis, a common side effect for oral cancer patients receiving radiation treatment. Alyzeh went over to the Pyxis machine to retrieve the medication.

The Pyxis machine is a medication dispensing unit that contains drawers to house various medications. When a user requests a medication from the Pyxis unit, only the drawer that contains that particular medication opens for the user.

As the drawer opened and Alyzeh reached for the medication to read the label and verify the medication, she realized that it was the wrong one. Reaching into an adjacent section of the drawer she picked up the mouthwash that she had been looking for.

October is ...



A 'good catch'

Recently, new Pyxis machines had been delivered to the clinic, which resulted in a change to which drawers held which medications.

The Pharmacy at UHN does some of its own packaging of medications so often some will look very similar. Typically medications with similar packaging are placed in different drawers of the Pyxis machine.

In this case both medications, one a mouthwash and the other a potassium liquid for electrolyte replacement, had nearly identical packaging and were housed in the same drawer. While both medications are in liquid form, the mouthwash is meant to be gargled and then spit out, whereas the potassium liquid is supposed to be ingested in order to take effect.

Identifying that this could potentially be a safety risk to patients, Alyzeh brought her concern to her manager, Lisa Tinker, and the rest of the team at the unit's morning Safety Huddle.

"After Alyzeh brought it up at huddle, we made sure everyone on the unit was aware of the issue and to take extra precautions with medications. I also brought it to the Leadership Safety Huddle to highlight Alyzeh's good catch and let the group know that we had connected with Pharmacy to come up with a solution," says Lisa, Nurse Manger in Ambulatory Care at the Princess Margaret.

Safety Huddles occur daily on units across the Princess Margaret and they are an opportunity for staff to share safety concerns.

Caring Safely

October is Caring Safely Month across UHN.

One of the key elements of Caring Safely, UHN's patient and workplace safety transformation, is embracing safety as a core value. That means everyone across the organization – clinical and non-clinical staff – is committed to improving safety both for one another and the individuals we serve.

"Our teams have embraced the safety huddles as a great opportunity to not only focus on safety, but also to support and recognize one another," says Marnie Escaf, Senior Vice-President at the Princess Margaret. "It is our staff at the Princess Margaret who provide exceptional care on a daily basis and we are committed to supporting them to continue to provide high-quality cancer care."

Finding a solution

To address the safety concern, Lisa enlisted the help of Tamara Rumsey in Inpatient Pharmacy who was able to check the inventory of the Pyxis unit and separate the two medications into different drawers to reduce the risk.

"I think the Safety Huddles have been great," says Lisa. "It's raised staff awareness of safety concerns and in almost all areas we're resolving roughly 95 per cent of the issues within 24 hours, so staff know when they speak up it's taken seriously and efforts are made to fix any issues in a timely manner."

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