Duplex bag Dose Delays/Omissions

PLEASE NOTE:   Posts made to this forum should not be considered as the expressed opinions of, nor should be considered endorsed by, the Medication Safety Officer’s Society (MSOS) or the Institute for Safe Medication Practices (ISMP). 

Make sure your email is up-to-date
In order to continue to receive updates from MSOS, as well as forum posts and other valuable information as a member of MSOS, please be sure to update your email address with us, whenever it changes. If you need assistance doing so, please send an email to jgold@ismp.org

1 post / 0 new
Stephanie Tupper
Stephanie Tupper's picture
Offline
Last seen: 1 week 3 days ago
Joined: 03/21/2021 - 23:05
Duplex bag Dose Delays/Omissions

I see this was discussed about 2 years ago, but I am wondering if this is a continuing issue for other facilities. Has anyone addressed the issue of delayed/omitted doses of medications due to nurses forgetting to activate or reconstitute duplex bags? We have had several recent errors in which an antibiotic dose was delayed or missed due to the RN forgetting to activate the bag. We have large red auxiliary labels that indicate activation is needed and have sent out education, but these errors have led us to re-evaluate. We currently use the duplex bags for meropenem and ceftriaxone.

Are your facilities still dispensing these bags to be activated on the unit? Has anyone implemented any changes that have helped prevent this issue?

Thanks so much for your help!

Tags: