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Kari Mortenson

Style GuidePunctuation

Always use serial commas in the text (e.g. red, white, and blue). Never use backslashes to indicate an and or or relationship in headings, subheadings, or

body text. Use backslashes to indicate an and or or relationship in headings or body text of tables,

graphs, and figures. Always use commas to mark thousands within numbers larger than 999 (e.g. 1,000). Always use a complete sentence before a colon is used in a sentence. Use a period to separate the table, graph, or figure number from the table’s title (e.g.

Table 1. Numbers). Never capitalize the first word after a colon unless it would otherwise be capitalized.

Numbers Write out all units of measurement within the text (e.g. percent). Use symbols for units of measurement in tables, graphs, and figures (e.g. %). Write out all numbers if they begin a sentence. Use words for quantities of ten or less in the text, unless the number is referring to an

appendix, table, or graph. Use numerals for quantities more than ten in the text. Use numerals for decimals. Use numerals for all numbers in tables, graphs, or figures. Write out the word zero when referencing no or none in statistics. Write out dates in format: month day, year or month year (e.g. July 4, 2015 or July 2015). Always use commas to mark thousands within numbers larger than 999 (e.g. 1,000).

Tables and Lists Always alphabetize the items in a bulleted list. Always alphabetize the items in a column of a table. Always capitalize the first letter of each item in a bulleted list or table. Always italicize the titles of tables, graphs, and figures. Use a period to separate the table, graph, or figure number from the table’s title (e.g.

Table 1. Numbers). Heading text for tables: 12 point, Arial font, Boldface Body text for tables: 10 point, Arial font

Type Style

Heading 1: 24 point, Arial font, Boldface Heading 2: 16 point, Arial font, Boldface Heading 3: 12 point, Arial font, Boldface Body text: 12 point, Times New Roman font Do not use underlining. Always italicize the titles of tables, graphs, and figures. Heading text for tables: 12 point, Arial font, Boldface Body text for tables: 10 point, Arial font

ABC against medical advice (ama) cell phone(s) Centers for Disease Control and Prevention (CDC)

DEF database e.g. follow-up Food and Drug Administration (FDA)

GHI healthcare Hennepin Regional Poison Center (HRPC) hydrocodone hydromorphone iatrogenic i.e.

JKL Joint Commission (TJC)

MNO meta-analysis

Microsoft Excel Data Analysis Minnesota MU non-critical non-healthcare non-pharmaceutical non-pharmacological North Dakota onsite opioid-naïve opioid(s) oxycodone

PQRS pain killer(s) pharmacists Pharm.D. pick up PubMed RefWorks sentinel South Dakota

TUV T-test teach-back-method therapeutic error timespan Toxicall tri-state twofold unintentional misuse United States

WXYZ

Methods:

HRPC Toxicall Data: Toxicall Search:

Data Collection:

Toxicall is the electronic record system utilized by the HRPC. This record system has

both a free note and a coding section for each case entered. The coding section is based mainly

upon type of call, type of exposure, and type of outcome of the call along with other data.

A retrospective review of HRPC data was performed utilizingemploying the search

criteria “therapeutic errors” and “unintentional misuse” for all calls received forconcerning two

medications: hydrocodone and oxycodone. Therapeutic errors occur when a patient is prescribed

a medication and the medication is taken/ or given incorrectly. Unintentional misuse typically

describes accidental use of a non-pharmacological product. Due to the potential for miscoding,

this review includes unintentional misuse cases were included for completeness in this review.

See Appendix 41 (page 43-44 44-45) for more information regarding what specific types of

exposure for are considered therapeutic errors and or unintentional misuse.

The data collected for this review is from January 2012 – June 2014 for therapeutic errors

and unintentional misuse. Data was also collected regarding all therapeutic errors, for

hydrocodone therapeutic errors and oxycodone therapeutic errors from 2002 – 2013. All data

was pulled from the HRPC database, which services athe tri-state area – of Minnesota, North

Dakota, and South Dakota. The HRPC does occasionally receive phone calls from other states

occasionally due to the cell phone use of cell phones. All calls are received through a 1-800

number and then routed to the appropriate regional poison center according to area code. Calls

received out of the tri-state are not excluded from included in this retrospective review.

Data Analysis

Toshiba-User, 12/04/15,

Do you think this “along with other data” is really necessary? It seems very open ended and I think you would be better off just focusing on the main components you mentioned before.


Since you use months in your reference above, you should either use months in your reference here or eliminate months from your first reference.


Your reader might find these two sentences confusing because they state that data was collected for different timeframes but don’t specify why these are references separately. You should make this clearer.


Since this appendix is mentioned first in the text it should be Appendix 1. This will also change what page number you reference so you should change the page number after switching the order of the appendices.


You specify what the coding section is based off from, but there is no explanation of what the free note section is. You should add one to help your reader understand this system fully.

Microsoft Excel Data Analysis tools were used for all statistical analyses. The total

number of calls received for oxycodone and hydrocodone therapeutic errors and unintentional

misuse was calculated and compared to the total number of therapeutic error calls received

inwithin the same time frame. From there, a percentage was generated to determine the percent

of therapeutic error callers who have had accidently overdosed on these two opioids within the

time span of this study this study’s timespan.

Microsoft Excel Data Analysis tools were used for all statistical analysis. The percentage

of oxycodone and hydrocodone specific therapeutic error calls was determined. The data on

therapeutic errors and unintentional misuse from 2012 – 2014 was analyzed through a T-test to

determine if there was a statistically significant increase in the number of calls from one year to

the next. Additionally, the percentage of all therapeutic error calls was analyzed for these the

same categories as well.

Literature Review Information

Accidental OverdoseInformation Collection

A retrospective literature review was performed to evaluate the current dosagesing,

overdose rates, and other information related to opioid medications. Databases used to complete

this literature review included PubMed and RefWorks to complete this literature review. Search

terms used included: opioid, opioid- naïve, counseling, dosing, overdosing, accidental,

inadvertent, adverse effects, pharmacist, therapeutic error, misuse, patient, health care team, and

guidelines. Combinations of search terms used included: pharmacist counseling opioids,

pharmacists review opioid dosing, patient opioid dosing, patient overdosing opioids, patient

accidental overdose opioids, pharmacist on health care team, patient inadvertent overdose

opioids, current opioid dosing guidelines, etc.


You may want to consider alphabetizing the lists in this paragraph.


The use of etc. here seems a bit too open-ended. Search terms used should be specific. Do you think the use of etc. fits well here?


Will all members of your audience be familiar with what a T-test is? If not, you might want to offer a definition.


As noted before, you should be consistent and reference all dates with month and year or all dates with only year. Also, earlier you referenced more data was used than just between 2012 and 2014. I think the reader might be confused about why only this data was analyzed this way and how the data from other years was analyzed. You should try to a little more clear here.

There is limited research relating to patients who accidently overdose on opioids

accidental opioid overdose in patients. A plethora of data is available related to intentional abuse

and misuse; however, this was not the topic of study here. All papers which containinged data

solely specific to opioid abuse and misuse and abuse were omitted from thise literature review.

Due to limited data, retrospective and meta-analysis studies were utilized for this literature

review.

Specific Iinclusion criteria was used when deciding which studies to include in this

literature review.: All studies used in this article included a patient population size greater than

10ten patients. Patients in each study arewere over the age 18 years old of age. All patients

provided informed consent for all studies. Patients who havehad been changed from one opioid

to another cancould still be considered for this studyreview. The Iindication for opioid

medication must have been pain management.

Specific Eexclusion criteria was used as well.: Patients who havehad been changed from

an opioid medication to other pain control willwere not be considered for this research. The only

indication considered in this study review iswas pain treatment; all other indications for opioids

willwere not be considered in this study.

Results:

Poison Center Data:

All Therapeutic Errors 2012 – 2014:

The HRPC Toxicall data shows a total of 19,672 calls were placed from 2012 – 2014

regarding a therapeutic error related to any medication. Of these calls, 17,327 (88.08% percent)

were managed at home with no need for the patient to seek medical attention. A total of 1,715

(8.72% percent) of callers were seen at / or admitted to a health care facility for evaluation.

Those admitted to a healthcare facility were broken down into subcategories as follows: 1,104

(5.61% percent) were treated /or evaluated and released, 96 (0.49% percent) were admitted to a

critical care unit, 268 (1.36% percent) were admitted to a non-critical care unit, 15 (0.08%

percent) were admitted to a psychiatric facility, 229 (1.16% percent) were lost to follow-up /or

left against medical advice, and 3three (0.02% percent) had an unspecified level of care. There

were 547 (2.78% percent) of callers who are listed as other. There arewere 72 (0.37% percent)

of callers who refused a referral and 11 (0.06% percent) of calls for which the level of care iswas

unknown. See Tables 1a and 1b in Appendix 1 2 for a summary of this data.

Hydrocodone Therapeutic Errors:

The HRPC Toxicall data shows a total of 284 calls to the HRPC regarding a therapeutic

error related to hydrocodone. Of these calls, 232 (81.69 percent) were managed at home with no

need for the patient to seek medical attention. A total of 39 (13.73% percent) callers were seen

at/ or admitted to a health care facility for evaluation. Those admitted to a health care facility

arewere broken down into subcategories as follows: 21(7.39% percent) were treated/ or

evaluated and released, 4four (1.41% percent) were admitted to a critical care unit, 7seven


Since you referenced the page number for the first appendix you mentioned, don’t you think it would be a good idea to reference the page number of this appendix to maintain consistency?


Be sure the consistency carries over to these dates as well.


Again, we need consistency with these dates: use both month and year or only year throughout the whole paper. And again, why are we only focused on the information gathered from these years for this section?

(2.46% percent) were admitted to a non-critical care unit, 1one (0.35% percent) werewas

admitted for psychiatric facility, and 6six (2.11% percetn) were lost to follow-up/ or left against

medical advice. There were 4four (1.41% percent) callers in the other category, and 9nine

(3.17% percent) callers who refused referral. See Tables 2a and 2b in Appendix 12 for a

summary of this data.

Hydrocodone Unintentional Misuse:

The Toxicall data shows a total of 22 calls to the HRPC regarding an unintentional

misuse related to hydrocodone. Of these calls, 13 (59.09% percent) were managed at home with

no need to be seen in a health care facility. A total of 9nine (40.91% percent) were seen at/ or

admitted to a health care facility for evaluation. Those admitted to a health care facility arewere

broken down into subcategories as follows: 5five (22.73% percent) were treated/ or evaluated

and released, 1one (4.55% percent) werewas admitted to a critical care unit, 3three (13.64%

percent) were admitted to a non-critical care unit. NoZero callers were lost to follow-up/ or left

against medical advice orand zero callers were recorded in the other or refused referral category.

See Tables 3a and 3b in Appendix 12 for a summary of this data.

Oxycodone Therapeutic Errors:

The Toxicall data shows a total of 294 calls to the HRPC regarding a therapeutic error

related to oxycodone. Of these calls, 240 (81.63% percent) were managed at home with no need

to be seen in a health care facility. A total of 50 (17.01% percent) were seen at /or admitted to a

health care facility for evaluation. Those admitted to a health care facility arewere broken down

into subcategories as follows: 29 (9.86% percent) were treated/ or evaluated and released, 3three

(1.02% percent) were admitted to a critical care unit, 8eight (2.72% percent) were admitted to a


Again, here you should reference a page number to maintain consistency.



non-critical care unit, 1one (0.34% percent) werewas admitted for psychiatric facility, and 9nine

(3.06% percent) were lost to follow-up/ or left against medical advice. There were 0zero callers

(0%) who refused referral. Additionally, 3three callers (1.02% percent) callers arewere listed as

other and 1one caller (0.34% percent) caller was listed as unknown. See Tables 4a and 4b in

Appendix 12 for a summary of this data.



Appendix 12: Results Data Tables

Category All Therapeutic Errors

Managed onsite 17,327

Managed at healthcare facility* 1,715

Other 547

Refused referral 72

Unknown 11

Total 19,672*Table 1b details the subcategories of cases admitted to healthcare facilities

Table 1a. All Therapeutic Error Calls to the Hennepin County Regional Poison Center from January 1, 2012 to June 30, 2014

Subcategory All Therapeutic Errors

Admitted to critical care unit 96

Admitted to non-critical care unit 268

Admited to psychiatric facility 15

Lost to follow-up/left against medical advice 229

Treated/evaluated and released 1,104

Unspecified level of care 3

Total 1,715

Table 1b. Subcategories of All Therapeutic Error Calls to the Hennepin Country Regional Poison Center Managed in a Healthcare Facility from January 1, 2012 to June 30, 2014


These two tables should replace Table 1. Putting the main categories and subcategories into two tables eliminates the gray areas making the tables more visually appealing and easier to understand. I’ve also included any other edits I suggest within these new tables.

Therapeutic Errors All

Category Subcategory Number

Managed on site/non-healthcare facility 17327

Managed in healthcare facilityTreated/evaluated and

released 1104

Admitted to critical care unit 96

Admitted to noncritical care unit 268

Admitted to psychiatric facility 15

Patient lost to follow-up/left AMA 229

Unspecified level of care 3Subtotal 1715

Other 547Refused referral 72

Unknown 11Total 19672

Table 1. All Therapeutic Errors from 1/1/2012 – 6/30/2014. This table provides the number of calls received in each category at the Hennepin County Regional Poison Center regarding therapeutic errors for any medication.


Refer to the previous page for edits.

Category All Therapeutic Errors

Hydrocodone Therapeutic Errors (Percent of Therapeutic Errors)

Managed onsite 17,327 232 (1.34%)

Managed at healthcare facility* 1,715 39 (2.27%)

Other 547 4 (0.73%)

Refused Referral 72 9 (12.50%)

Unknown 11 0 (0.00%)

Total 19,672 284 (1.44%)*Table 2b details the subcategories of cases admitted to healthcare facilities

Table 2a. All Hydrocodone Therapeutic Error Calls to the Hennepin County Regional Poison Center from January 1, 2012 to June 30, 2014

Subcategory All Therapeutic Errors

Hydrocodone Therapeutic Errors (Percent of Therapeutic Errors)

Admitted to critical care unit 96 4 (4.17%)

Admitted to non-critical care unit 268 7 (2.61%)

Admitted to psychiatric facility 15 1 (6.67%)

Lost to follow-up/left against medical advice 229 6 (2.62%)

Treated/evaluated and released 1,104 21 (1.90%)

Unspecified level of care 3 0 (0.00%)

Total 1,715 39 (2.27%)

Table 2b. Subcategories of All Hydrocodone Therapeutic Error Calls to the Hennepin Country Regional Poison Center Managed in a Healthcare Facility from January 1, 2012 to June 30, 2014


These two tables should replace Table 2. I suggest putting the main categories and subcategories into two tables to make them more visually appealing and easier to understand. Also, combining the percent and number columns helps conserve space. I also included any other edits I suggest within these new tables.

Therapeutic Errors All Hydrocodone Therapeutic Error

Category Subcategory Number Number Percent of TEManaged on

site/non-healthcare

facility 17327 232 1.34%Managed in healthcare

facilityTreated/evaluated

and released 1104 21 1.90%

Admitted to critical care unit 96 4 4.17%

Admitted to noncritical care

unit 268 7 2.61%Admitted to psychiatric

facility 15 1 6.67%Patient lost to follow-up/left

AMA 229 6 2.62%Unspecified level

of care 3 0 0.00%Subtotal 1715 39 2.27%

Other 547 4 0.73%Refused referral 72 9 12.50%

Unknown 11 0 0.00%Total 19672 284 1.44%

Table 2. Therapeutic Errors and percentage of errors for Hydrocodone from 1/1/2012 – 6/30/2014. This table provides the number of calls received in each category at the Hennepin County Regional Poison Center regarding therapeutic errors for any hydrocodone.



Category All Therapeutic Errors Hydrocodone Unintentional Misuse

(Percent of Therapeutic Errors)

Managed onsite 17,327 13 (0.08%)


Other 547 0 (0.00%)

Refused referral 72 0 (0.00%)

Unknown 11 0 (0.00%)


Table 3a. All Hydrocodone Unintentional Misuse Calls to the Hennepin County Regional Poison Center from January 1, 2012 to June 30, 2014

Subcategory All Therapeutic Errors Hydrocodone Unintentional Misuse

(Percent of Therapeutic Errors)







Total 1,715 9 (0.52%)

Table 3b. Subcategories of All Hydrocodone Unintentional Misuse Calls to the Hennepin Country Regional Poison Center Managed in a Healthcare Facility from January 1, 2012 to June 30, 2014


These two tables should replace Table 3. Again, I suggest putting the main categories and subcategories into two tables to make them more visually appealing and easier to understand. Also, combining the percent and number columns helps conserve space. I also included any other edits I suggest within these new tables.

Therapeutic Errors All Hydrocodone Unintentional Misuse


site/non-healthcare









of care 3 0 0.00%Subtotal 1715 9 0.52%


Unknown 11 0 0.00%Total 19672 22 0.11%

Table 3. Unintentional Misuse of Hydrocodone and percentage calls from 1/1/2012 – 6/30/2014. This table provides the number of calls received in each category at the Hennepin County Regional Poison Center regarding unintentional misuse calls for hydrocodone.



Category All Therapeutic Errors Oxycodone Therapeutic Errors (Percent of

Therapeutic Errors)

Managed onsite 17,327 240 (1.93 %)


Other 547 3 (0.55%)

Refused referral 72 0 (0.00%)

Unknown 11 1 (9.09%)


Table 4a. All Oxycodone Therapeutic Error Calls to the Hennepin County Regional Poison Center from January 1, 2012 to June 30, 2014

Subcategory All Therapeutic Errors Oxycodone Therapeutic Errors (Percent of

Therapeutic Errors)







Total 1,715 50 (2.92%)

Table 4b. Subcategories of All Oxycodone Therapeutic Error Calls to the Hennepin Country Regional Poison Center Managed in a Healthcare Facility from January 1, 2012 to June 30, 2014


These two tables should replace Table 4. Again, I suggest putting the main categories and subcategories into two tables to make them more visually appealing and easier to understand. Also, combining the percent and number columns helps conserve space. I also included any other edits I suggest within these new tables.

Therapeutic Errors All Oxycodone Therapeutic Error


site/non-healthcare









of care 3 0 0.00%Subtotal 1715 50 2.92%


Unknown 11 1 9.09%Total 19672 294 1.49%

Table 4. Therapeutic Errors for oxycodone and percentage of errors from 1/1/2012 – 6/30/2014. This table provides the number of calls received in each category at the Hennepin County Regional Poison Center regarding therapeutic errors for oxycodone.



Appendix 41: Definitions and Further

Explanation

Therapeutic Error Definition according to Toxicall:

According to Toxicall, a therapeutic error Ooccurs when a patient’s prescription medication

which is prescribed for a patient is taken/ or given incorrectly. for a variety of different reasons.

Therapeutic Eerrors include:

Incorrect dispensing route

Dispensing cup error

10ten-fold dosing error

Inadvertently took/ or givengave medication twice

Incorrect formulation or concentration dispensed

Wrong medication taken/ or given

Health professional/ or iatrogenic error (e.g. pharmacist/,nurse/,physician)

Exposure through breast milk

More than 1one product containing the same ingredient

Medication doses given/ or taken too close together

Confused units of measure

Other incorrect dose

Drug interactions

Other/ or unknown therapeutic error


This list should be alphabetized.

Unintentional Misuse Definition According to Toxicall:

According to Toxicall, unintention misuse is the Uunintentional, improper, or incorrect use of a

non-pharmaceutical substance. Unintentional misuse differs from intentional misuse in that

because the exposure was unplanned or not unforeseen by the patient. Unintentional misuse

Iincludes:

A person who mMisread or unread (or didn’t read) a product label

Exposure through incorrect use of a product

Exposure occurred due to forgetfulness that product was placed in a different receptacle

than its typical packaging.


Again, this list should be alphabetized.

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