Multi-dose vial management The Centers for Disease Control and Prevention administration rather than multi-dose vials due to the (CDC) and the World Health Organization (WHO) risk of cross contamination and the potential to have developed recommendations and guidelines administer too high of a dose to patients.6 regarding best practices for infection control. These recommendations and guidelines stress the Multi-dose vial use summary recommendations importance of single-dose or single-use vials for from CDC and WHO parenteral administration of medications. Several
Avoid or strictly limit the use of multi-dose vials.
studies reviewed by these two organizations reported
Use single-dose, preservative-free medications for a
that multi-dose vials were identified as a potential source of infection, despite the presence of
Discard single-use vials and ampules after the
preservatives to reduce bacterial survival.1,2 The
contents have been drawn up into a syringe and
studies also found that multi-dose vial handling and
discard the syringe after use on a single patient.
poor technique by healthcare workers were
If multi-dose vials must be used, aseptic technique
contributing factors to the incidence of hospital
Cleanse the vial diaphragm or septum with 70%
The Joint Commission has established National Patient
alcohol before inserting an access device (needle
Safety Goals (NPSGs) in conjunction with the Standards for Hospital Accreditation Program. There are two 2012
Use only sterile, single-use syringes and access
NPSGs that apply to multi-dose vial use. Goal 3 is “Use
devices and discard them after each use.
Medications Safely” and Goal 7 is “Prevent Infections.” The Joint Commission Medication Management Standard
contaminated once it has been used to enter or
3.01 in combination with NPSGs 3 and 7 require
connect to a patient’s intravenous infusion bag
processes, policies and monitoring of practices that
Do not leave access device in diaphragm or septum.
The American Society of Anesthesiologists (ASA)
Discard multi-dose vials if there is any suspected
Recommendations for Infection Control for the Practice of Anesthesiology has identified that there is potential
Documentation on the multi-dose vial label should
risk of infection with the use of multi-dose vials,
include the revised expiration date (or “beyond use”
especially when aseptic technique has not been
date, which is 28 days after opening) and the initials
maintained or opened vials are not properly managed and labeled.3 The recommendations suggest that in
Refrigerate any opened and properly labeled
areas such as the operating room (OR), where there is a
medication as recommended by the manufacturer.
higher volume of critically ill patients, there are more
Discard opened multi-dose vials 28 days after
opportunities for breaks in aseptic technique. Therefore,
opening. If the manufacturer’s original expiration
the trend is to use single dose vials or to discard multi-
date is shorter than the revised expiration date,
dose vials after use on a single patient.The Association of periOperative Registered Nurses
Currently, vaccines are exempt from this
(AORN) 2012 edition of Perioperative Standards and
requirement and are to be discarded per the
Recommendations for medication safety now includes
manufacturer’s expiration date, provided they are
recommendations for collaborating with pharmacy to
stored and handled according to manufacturer’s
procure and store single dose vials for medication Setup for multi-dose vials Examples of formulary setup
Due to medication supply shortages pharmacies may
have to supply medications in the multi-dose or multi-
The hospital charge master and patient billing system
must support the multi-dose medication vial process to
assure compliance with government and third-party
payer regulations. Coordinating multi-dose medication
practice with hospital financial systems and policies
will help assure successful billing audits and avoid
disputes as well as potential fines for patient billing
The Pyxis® system formulary and the hospital billing
system need to be setup to dispense and bill for each
milligram or milliliter of medication used from a multi-
dose vial. Once the setup for both is complete, thorough
testing of the process from dispensing via the Pyxis®
Anesthesia System or Pyxis MedStation® system to the
usage messages sent to and received by the hospital
In the examples listed, the dosage form is the key
billing system must occur to validate consistently
element in setting up the formulary correctly. The
dosage form drives the dispensing, refilling and patient charging. The minimum and maximum par levels should
be established in multiples of the dosage form that
The vials should be loaded in the Pyxis system with a
equal a whole vial to facilitate replenishment. Including
quantity based on the dosage form. In the example
the size of the vial and the milligrams per milliliter
below, the minimum par level is 400 mg and a
(mg/mL) in the generic medication description are
helpful in facilitating accurate picking and refilling for
Example: Labetalol 5mg/mL, 20 mL vial (100 mg/vial)
Desired Min = 4 vials Desired Max = 6 vials
Dispensing Refilling
When dispensing for a patient, the user should enter
For the Labetalol example, refilling is done in
the total amount of milligrams or milliliters needed for
amounts of 100 mg rounded down to the nearest
the dose. In the Labetalol example, if a dose of 20mg
whole unit or vial. For example, if the refill report
is needed, the quantity of 20 will need to be accounted
indicated that 425 mg of Labetalol was needed to
refill the device, then 400 mg or 4 vials should be
If the Pyxis Anesthesia system My Items and/or Transfer to Patient features are being considered for
use, thorough testing of the entire process must be completed to ensure billing accuracy. The hospital
pharmacy and financial systems must be able to receive the desired billing and credit quantities from the Pyxis Training
product interface. The testing should include end users
Include training on the handling of multi-dose vials in
such as anesthesia providers and nurses working
implementation training as well as ongoing new user
through their processes. End users should test all of the training for the Pyxis Anesthesia System. Anesthesia process steps from dispensing to the transfer of multi-
providers and other clinical end users require training
dose vial quantities via the Pyxis Anesthesia system with on dispensing, wasting and returning. Pharmacy staff the My Items and/or Transfer to Patient features
requires training on loading, refilling, unloading and
supporting clinical end users on multi-dose vial process questions.
Policy and procedure
Clearly outline the processes for the management of multi-dose vials for pharmacy, anesthesia providers and other applicable clinical end users in the Pyxis system policy and procedure. The defined processes for replenishment and dispensing should be part of user training. Include all dispensing scenarios: individual patient and transfer processes for the My Items and Transfer to Patient features, if
1 Bulletin of the World Health Organization 2003; 81:491-500.
2 Centers for Disease Control and Prevention (CDC): Preventing Transmission of Infectious Agents in Healthcare Settings 2007, Recommendation
3 American Society of Anesthesiologists: Recommendations for Infection Control for the Practice of Anesthesiology, second edition, 1999.
4 The Joint Commission: “Standards FAQ Details” on Multi-dose vials (July 20, 2010).
5 Centers for Disease Control and Prevention (CDC): Safe Injection Practices to Prevent Transmission of Infections to Patients, May 21, 2010. 6 ISMP Medication Safety Alert-Acute Care Newsletter January 26, 2012. 2012 CareFusion Corporation or one of its subsidiaries. All rights reserved. Pyxis, Pyxis MedStation system, and Pyxis Anesthesia system are trademarks or registered trademarks of CareFusion Corporation or one of its subsidiaries. All other trademarks are the property of their respective owners.
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DC Dental Central Großhandelsges.mbH Carl-Zeiss-Str.2 D-22946 Trittau, Germany 2. Composition/information on ingredients Description: Compomere based on methyl methacrylate May cause sensitization on skin contact. In case of inhalation remove casualty to fresh air and allow to rest. Iff irritation persists seek medical device. In case of contact with skin wash off immediately with soap and
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