MEDICATION ERRORS and INTERACTIONS – Things to keep in mind
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Transcript of MEDICATION ERRORS and INTERACTIONS – Things to keep in mind
MEDICATION ERRORS and INTERACTIONS –Things to keep in mind
Linda E. Pelinka, MD, PhD, Medical University of Vienna,
and Boltzmann Institute for Experimental & Clinical Traumatology
Vienna, Austria, European Union
TRAUMA
““Errors in judgement Errors in judgement
must occur must occur
in the practice of in the practice of
an art an art
which consists largely in which consists largely in
balancing probabilities.”balancing probabilities.”
Sir William OslerSir William OslerBritish Royal College of Physicians 1883British Royal College of Physicians 1883Physician in chief, Johns Hopkins Hospital 1888Physician in chief, Johns Hopkins Hospital 1888Author of Principles & Practice of MedicineAuthor of Principles & Practice of Medicine
1 drug error per 133 anesthetics
7 drug errors/AP/year
if 1% of errors resulted in injury…
Every AP would harm 2 pts in a 30 yr career
1000 APs would harm 2000 pts
Glavin RJ. Br J Anaesth 2010; 105/1: 76-82.
Anesthesia professionals in the OR are the only med personnel who
Martin DE, Penn State College of Medicine. APSF Consensus Conf. 2010
PrescribePrescribeSecure Secure PreparePrepareAdminister and Administer and Document medications… Document medications…
…a process of up to 41 steps.
These steps usually occur within a very short time interval,
Martin DE, Penn State College of Medicine. APSF Consensus Conf. 2010
typically without standardized protocols and often in a distracting environment.
…a process of up to 41 steps.
Poor lighting Cluttered space Noise Interruption Multi-tasking
Grissinger M, Ann Meeting American Pharmacists Ass 2007, Atlanta, GA
Key System Elements that influence medication use most
Cranshaw J et al. Anaesthesia 2009; 64: 1317-23.
Litigation related to Drug Errors in
Anaesthesia: Analysis of Claims
against the NHS in England 1995-2007
Cranshaw J et al. Anaesthesia 2009; 64: 1317-23.
93 claims62 drug administration errors
31 wrong drug
>50% neuromuscular
blockers
25 wrong dose >30% opioid
overdose incl neuraxial route
Syringe swaps,
Labeling,
Routes of administration
Male, age 58, Syringe Swap
Choosing between only 2 syringes,
both known to contain high-risk drugs,
the provider ASSUMED instead of
reading the syringe label,
before injecting the WRONG DRUG
by the WRONG ROUTE.
100% YES to all 3 questions
Kulli JC, webmm.ahrq.gov
Survey of AP
1.Do you ever carry drugs in your pocket?
2.Does every anesthesiologist you know carry drugs in a pocket?
3.Do you think it’s safe to do so?
Orser BA et al.Can J Anaesth 2001; 42/2:139-46.
Most common error: administration of a
muscle relaxant instead of a reversal agent.
Most common contributing factors: Syringe
swaps (70%), label misidentification (47%)
Most anesthesiologists (98%) reported reading
the ampoule label “most of the time”.
Label color was an important secondary cue.
Medication Errors in Anesthetic Practice: Survey of 687 Practitioners
Fasting S, Gisvold SE. Can J Anesth 2000; 47/11: 1060-67.
In 27 of 28 cases, In 27 of 28 cases,
swaps occur swaps occur
between between
SAME SIZE SYRINGESSAME SIZE SYRINGES
Fasting S and Gisvold SE. Can J Anesth 2000; 47/11: 1060-67.
Syringe swaps occurred most often between syringes of equal size. Neither large letters nor colour coding were a strong enough visual cue to prevent errors.
Almost no swaps occurred between syringes of different sizes. Using one size of syringe for only one group of drugs might be a strong enough visual cue to reduce syringe swaps.
Adverse Drug Errors in Anesthesia. Impact of Coloured Syringe Labels.
Most frequent Syringe Swaps
FENTANYL intended
NEOSTIGMINE intended
MIDAZOLAM intended
SUCCINYLCHOLINE given
SUCCINYLCHOLINE or NM BLOCKER given
SUCCINYLCHOLINE or NM BLOCKER given
Abeysekera A et al. Anaesthesia 2005; 60: 220-27.
Cranshaw J et al. Anaesthesia 2009; 64: 1317-23.
Most common adverse outcomes: Awake paralysis Resp depression requiring ICU
15 errors resulted in severe harm or death
Litigation related to Drug Errors in Anaesthesia: Analysis of Claims
against the NHS in England 1995-2007
Llewellyn RL et al. Anaesth Intensive Care 2009; 37/1: 93-8.
Hospitals A&C treat adults, hospital B peds. Response rates: A+C 48%, B 81%
Most common errors, A+C: substitution.
B: substitution & incorrect dose.
Causes for amp & syringe swaps (substitution errors): 21% syringe misidentification, 37% AMPOULE LOOK-ALIKES.
Drug Administration Errors: a prospective Survey from 3 South
African Teaching Hospitals
Ge Li, MD, PhD, Elgin IL. www.apsf.org/newsletters/html/2009/winter/13_lookalikes.htm
To the Editor:
I administered anesthesia to a 4 yr old, 15 kg
girl for tonsillectomy and adenoidectomy.
Because of the size of the tonsils, the surgeon
requested 20 mg of dexamethasone iv.
Glycopyrrolate was in the same drug tray,
close to the dexamethasone vial.
Look-alike Drugs Cause Near Miss
Luckily, I checked the label.
I think this “look-alike” is something important
and that every anesthesiologist and anesthetist
should be aware of the similarity.
Ge Li, MD, PhD, Elgin IL. www.apsf.org/newsletters/html/2009/winter/13_lookalikes.htm
I was to give 5 dexamethasone vials (4mg/vial).
5 glycopyrrolate vials (0.4mg/vial) would
have been at least 10 times more than the max
allowable dose.
Look-alike Drugs Cause Near Miss
Similar very small writing on ampSimilar very small writing on ampSame manufacturerSame manufacturerSame sizeSame size
Amp/Vial SwapsAmp/Vial Swaps
Amp/Vial Swaps
Amp/Vial SwapsAmp/Vial Swaps
Wrong route:
The most significant factor of this section was
the large number of errors associated with
regional anesthesia, despite using the normal
checks, including aspiration to check for blood.
Drug Error in Anaesthetic Practice: Review of 896 Reports from the
Australian Incident Monitoring Study Database.
Abeysekera A et al. Anaesthesia 2005; 60: 220-27.
Local Anesthetics: Baricity, Local Anesthetics: Baricity, Concentration, AdditivesConcentration, Additives
The problem of cross-connection of anesthesia gasses
recognized >50 years ago.
Has been almost eliminated by
mandated use of incompatible
connectors for different gasses.
Compatible Cross Connection
Preventing catheter/tubing misconnections: Much needed help is on the way. ISMP Medication Safety Alert! Acute Care Edition.
July 15, 2010; 15: 1-2.
Shared by different tubing devices
used in patient care,
includingPeriperal cathetersEpidural cathetersIV syringes
Kulli JC, webmm.ahrq.gov
Luer Connector System
Prescribing
Errors
Most Common Prescribing Errors 1
Lack of
PATIENT knowledge
other medsdrug interaction
allergy
Lack of
DRUGknowledge
wrong dosewrong frequency
Key System Elements that influence medication use
the most
Pt info: age, weight, diagnoses, allergies
CommunicationGrissinger M, Ann Meeting American Pharmacists Ass 2007, Atlanta, GA
Cockroft DW and Gault MH. Prediction of Creatinine Clearance from Serum Creatinine. Nephron 1976; 16: 31-41.
Unfractionated heparin & LMWHGlycoprotein IIb/IIIa receptor antagonistsFibrinolytic agents (alteplase, tenecteplase)Inotopes (dobutamine)Vasopressors (dopamine, norepinephrine)Vasodilators (nesiritide, nitroprusside)Inodilator milrinone
Body Weight Over- & Underestimation,
common cause of medication errors
Drugs most commonly misused
by health care professionals
Grissinger M, Ann Meeting American Pharmacists Ass 2007, Atlanta, GA
4) Hydrocodone
5) Ibuprofen
6) Acetaminophen
7) Aspirin
2)Anticoagulants
3)Antibiotics
1)Insulin
Creatinine ClearanceCorrect estimation is one of
the most important factors in dosing
Cockroft DW and Gault MH. Prediction of Creatinine Clearance from Serum Creatinine. Nephron 1976; 16: 31-41.
EnoxaparinEnoxaparinEptifibatideEptifibatideTirofibanTirofibanBivalirudinBivalirudinDofetilideDofetilideSotalolSotalol
Top 5 of 355 drugs most Top 5 of 355 drugs most commonly associated with errorscommonly associated with errors
Analgesics AntibacterialsBronchodilators Anti-anginals
Glavin RJ. Br J Anaesth 2010; 105/1: 76-82.Glavin RJ. Br J Anaesth 2010; 105/1: 76-82.
Claims involving Claims involving Allergic ReactionsAllergic Reactions n=31n=31
65%Previously KNOWN allergen>30% Penicillin20% severe reactionNo lasting sequelae
35%Previously UNKNOWN allergen45% death40% cardioresp arrest CNS damage
Cranshaw J et al. Anaesthesia 2009; 64: 1317-23.Cranshaw J et al. Anaesthesia 2009; 64: 1317-23.
despite allergy or contra-indication
Overdose: entire amp given at once
Blood to wrong pt
drug forgotton
given too fast
drug expired
syringe already used
%
Drug administration errorsDrug administration errors
Abeysekera A et al. Anaesthesia 2005; 60: 220-Abeysekera A et al. Anaesthesia 2005; 60: 220-7.7.
Most Common Prescribing Errors 2
MisCALCULATINGDose Calculation Error
Decimal Point Misplacement
Drugs most commonly Drugs most commonly misprepared misprepared
by health care professionalsby health care professionals
Morphine
dilution error
NM BLOCKER prepared instead of neostigminVECURONIUM dilution error: H20 w/o vec
Abeysekera A et al. Anaesthesia 2005; 60: 220-27.Abeysekera A et al. Anaesthesia 2005; 60: 220-27.
Cranshaw J et al. Anaesthesia 2009; 64: 1317-23.
Most common adverse outcomes: Awake paralysis Respiratory depression requiring ICU
15 errors resulted in severe harm or death
Litigation related to Drug Errors in Anaesthesia: Analysis of Claims
against the NHS in England 1995-2007
Although iatrogenic opioid overdosing
is a recurrent error reported to the NRLS*, it seems
rarely reported in the context of anesthetic care.
*National Patient Safety Agency National Reporting & Learning Service
Cranshaw J et al. Anaesthesia 2009; 64: 1317-23.
Most Common Prescribing Errors 3
MisUNDERSTANDINGMisreading,
use of Abbreviations
Letters & Numerals commonly confused
oo 00cc eegg qqmm nnyy zz
EE FFZZ 22OO 00DD 00SS 88
ZZ 77TT II55 8855 3377 11
Lavin LA, Prescribing ErrorsSt Louis University APNursing Conference, 2012
Cursive Letters & Numerals commonly confused
11 77ii eeaa oo
ff 77gg 99BB 88
Confused Drug Names 1Confused Drug Names 1Drug name Confused with
Zyrtec*Zyrtec* Zyprexa*Zyprexa*
Trental*Trental* Tegretol*Tegretol*
dimenhydrinatedimenhydrinate diphenhydraminediphenhydramine
dobutaminedobutamine dopaminedopamine
chlorpromazinechlorpromazine chlorpropamidechlorpropamide
Beano*Beano* B&O* B&O* belladonna&opiumbelladonna&opium
desipraminedesipramine disopyramidedisopyramidewww.ismp.org, Institute for Safe Medication Practices, Institute for Safe Medication Practices
Dimenhydrinate and Dimenhydrinate and DiphenhydramineDiphenhydramine
http://medicscribe.com/2010/05/medication-errors-epinephrinehttp://medicscribe.com/2010/05/medication-errors-epinephrine
Dimenhydrinate = Dimenhydrinate = DRAMAMINEDRAMAMINEDiphenhydramine = Diphenhydramine = BENADRYLBENADRYL
Dimenhydrinate is an anti-emeticDimenhydrinate is an anti-emeticDiphenhydramine is an anti-histaminicDiphenhydramine is an anti-histaminic
Both vials same colorBoth vials same colorBoth have long names beginning with DBoth have long names beginning with DBoth often stored beside each other in kitBoth often stored beside each other in kit
Confused Drug Names 2Confused Drug Names 2Drug name Confused with
sufentanylsufentanyl fentanylfentanyl
tramadoltramadol trazodonetrazodone
ephedrineephedrine epinephrineepinephrine
Ketalar*Ketalar* ketorolacketorolac
hydrocodonehydrocodone oxycodoneoxycodone
hydromorphonehydromorphone morphinemorphine
Norcuron*Norcuron* Narcan*Narcan*www.ismp.org, Inst. f. Safe Medication Practices, Inst. f. Safe Medication Practices * brand name
Confused Drug Names 3Confused Drug Names 3Drug name Confused with
clonidineclonidine clozapine, clonazepamclozapine, clonazepam
lorazepamlorazepam Lovaza*Lovaza*
Humalog*Humalog* Humulin*Humulin*
Nexium*Nexium* Nexavar*Nexavar*
nifedipinenifedipine Nimodipine, nicardipineNimodipine, nicardipine
iodineiodine Lodine*Lodine*
Lamisil*Lamisil* Lamictal*Lamictal*
www.ismp.org, Institute for Safe Medication Practices* brand name
Confused Drug Names 4Confused Drug Names 4Drug name Confused with
Dioval*Dioval* Diovan*Diovan*
Dilaudid-5*Dilaudid-5* Dilaudid*Dilaudid*
disopyramidedisopyramide desipraminedesipramine
Evista*Evista* Avinza*Avinza*
Neo-Synephrine Neo-Synephrine (oymetazoline)(oymetazoline)
Neo-Synephrine Neo-Synephrine (phenylephrine)(phenylephrine)
methadonemethadone Metadate*, Mephyton*Metadate*, Mephyton*
www.ismp.org, Institute for Safe Medication Practices, Institute for Safe Medication Practices
Drug Interaction
SEROTONIN = 5-HYDROXY-TRYPTAMINE
DECREASE METABOLISMMAO Inhibitors:
IsocarboxazidSelegiline (Antiparkinson)
PhenelzineTranylcypromine
MoclobemideAntibiotic Linezolid
Methylene blue
L Tryptophan
Modified according to Rastogi R et al,
Anesthesiology 2011; 115: 1293
INCREASE RELEASEAmphetamines
CocaineEcstasyOpioids
FenfluramineSibutramine
Phenantherene
Modified according to Rastogi R et al,
Anesthesiology 2011; 115: 1293
L Tryptophan
INCREASED INCREASED SEROTONIN RECEPTOR SEROTONIN RECEPTOR
SENSITIVITYSENSITIVITYLithiumLithium
Modified according to Rastogi R et al,
Anesthesiology 2011; 115: 1293
L Tryptophan
SEROTONIN RECEPTOR SEROTONIN RECEPTOR AGONISTSAGONISTS
LSDLSDLysergic acid diethylamideLysergic acid diethylamideDHE Di-hydro ergotamineDHE Di-hydro ergotamine
BuspironeBuspironeTriptansTriptans
MirtazapineMirtazapine
Modified according to Rastogi R et al,
Anesthesiology 2011; 115: 1293
L Tryptophan
RE-UPTAKE INHIBITORS
SSRI Select. Serotonin Reuptake Inhibitors
SNRI Serotonin Noradrenalin Re-uptake Inhibitors
5 HT3 AntagonistsAntidepressants
OpioidsHerbs
Mod. according to Rastogi R et al, Anesthesiology 2011; 115: 1293
L Tryptophan
SSRIEscitolopramCitalopramParoxetineFluoxetineSertraline
OPIOIDSFentanylMethadoneMeperidineDextromethorphanTramadol
SNRIDuloxitineVenlafaxineMilnacipran
5 HT3 ANTAGONISTSOndansetronGranisetron
Herbs GinsengSt John’s Wort
ANTIDEPRESSANTSAmitryptiline, Imipramine, Clomipramine, Desipramine, Trazodone, Nefazodone
Serotonin Re-Uptake Inhibitors
SSRI Selective Serotonin Re-uptake Inhibitors SNRI Serotonin Noradrenalin Re-Uptake Inhibitors
Inhibited Inhibited SerotoninSerotoninRe-uptakeRe-uptake
OPIOIDSHAVE A DUAL EFFECT
IncreasedSerotonin
release
Differential Diagnosis 1Condition Pupils Skin Bowel sounds
Serotonin Syndrome
Mydriasis Diaphoresis hyperactive
Anticholinerg “toxidrome”
Mydriasis Erythema hot, dry
decreased or absent
Neurolept malignant
Normal Diaphoresis, pallor
decreased or normal
Malignant hypertherm
Normal Diaphoresis , mottled
decreased
Boyer EW, Shannon M. NEJM 2005; 352/11: 1112-20. Boyer EW, Shannon M. NEJM 2005; 352/11: 1112-20.
Differential Diagnosis 2Differential Diagnosis 2Condition Drugs
takenTime to develop
Vital signs
Serotonin Syndrome
Prosero tonergic
<12h Hypertens., Tachycardia, Tachypnia, >41.1C
AnticholinergAnticholinerg“toxidrome”“toxidrome”
AnticholinAnticholinergicergic
<12h<12h Hypertens., Tachycardia,Hypertens., Tachycardia,Tachypnia, <38.9CTachypnia, <38.9C
Neurolept Neurolept malignantmalignant
Dopamine Dopamine antagonisantagonistt
1-3 days1-3 days Hypertens., Tachcardia, Hypertens., Tachcardia, Tachypnia, >41.1CTachypnia, >41.1C
Malignant Malignant hyperthermhypertherm
Sux, Inhal Sux, Inhal anestheticanesthetic
30min 30min -24h -24h
Hypertens., Tachcardia, Hypertens., Tachcardia, Tachypnia, up to 46CTachypnia, up to 46C
Boyer Shannon M. NEJM 2005; 352/11: 1112-20. Boyer Shannon M. NEJM 2005; 352/11: 1112-20.
Differential Diagnosis 3Differential Diagnosis 3Condition Musc tone Reflexes Mental Status
Serotonin Syndrome
Increased,more lower extremity
Hyper, clonus (unless masked)
Agitation, coma
Anticholinerg Anticholinerg “toxidrome” “toxidrome”
normalnormal normalnormal Agitated Agitated deliriumdelirium
Neurolept Neurolept malignantmalignant
““lead pipe” lead pipe” rigidityrigidity
Brady Brady reflexiareflexia
Stupor, alert Stupor, alert mutism, comamutism, coma
Malignant Malignant hyperthermhypertherm
Rigor mortis-Rigor mortis-like rigiditylike rigidity
HypoHyporeflexiareflexia
AgitationAgitation
Boyer EW, Shannon M. NEJM 2005; 352/11: 1112-20. Boyer EW, Shannon M. NEJM 2005; 352/11: 1112-20.
The Serotonin Syndrome
1) The serotonin syndrome is a predictable consequence of excess serotonergic agonism of CNS & peripheral serotonergic receptors.
2) Excess serotonin may produce a wide spectrum of clinical findings.
3) Clinical manifestations range from barely perceptible to lethal.
Boyer EW, Shannon M. NEJM 2005; 352/11: 1112-20.
Life Life ThreateningThreatening
ToxicityToxicity
Altered Mental StateRestlessness
Clonus(sustained) HyperthermiaHyperthermia
Muscular Muscular HypertonicityHypertonicity
TremorClonus
(inducible)
Mild Symptoms
MILDADVERSEREACTION
AnxietyAkathisiaTremor
TachycardiaSweatingDiarrhea
Mydriasis
FULLBLOWN
SEROTONINSYNDROME
ClonusHyper-reflexiaHyper-thermia
Hypertension
SEVERESEROTONIN
TOXICITYRigidity
>40CSeizureComa
Discontinue offending
drug(s)
Add. monitoring,hydration, cooling
oxygenation
SEVERESEROTONIN
TOXICITYRigidity
>40CSeizureComa
ICUIntubate & Ventilate
Muscle RelaxantsDialysis
5 HT AntagonistsCYPROHEPTADINE poCHLORPROMAZINE ivBenzosAnticonvulsantsßBlocker Propranolol
The Libby Zion Case
18 yr old patient undergoing psychiatric therapy for
stress: phenelzine, Percodan (aspirin-oxycodone
hydrochloride).
Fever and otalgia: Erythromycin, chlorphenamine
History: cocaine, marihuana, imipramine,
flurazepam, diazepam.
After admission: Acetaminophen, haloperidol,
meperidine.
Asch DA, Parker RM. NEJM 1988; 318/12: 771-5.
TAKE HOME
MESSAGES
Anesthesia errors happen to almost every AP
sooner or later.
Kulli JC, webmm.ahrq.gov
The frequency of drug errors in anesthesia is probably much higher than
reported (definition of error).
Fasting S, Gisvold SE. Can J Anesth 2000; 47/11: 1060-67.
In 27 of 28 cases, In 27 of 28 cases,
swaps occur swaps occur
between between
SAME SIZE SYRINGESSAME SIZE SYRINGES
Most frequent Syringe Swaps
FENTANYL intended
NEOSTIGMINE intended
MIDAZOLAM intended
SUCCINYLCHOLINE given
SUCCINYLCHOLINE or NM BLOCKER given
SUCCINYLCHOLINE or NM BLOCKER given
Abeysekera A et al. Anaesthesia 2005; 60: 220-27.
Drugs most commonly misused
by health care professionals
Grissinger M, Ann Meeting American Pharmacists Ass 2007, Atlanta, GA
4) Hydrocodone
5) Ibuprofen
6) Acetaminophen
7) Aspirin
2)Anticoagulants
3)Antibiotics
1)Insulin
Drugs most commonly Drugs most commonly misprepared misprepared
by health care professionalsby health care professionals
Morphine
dilution error
NM BLOCKER prepared instead of neostigminVECURONIUM dilution error: H20 w/o vec
Abeysekera A et al. Anaesthesia 2005; 60: 220-27.Abeysekera A et al. Anaesthesia 2005; 60: 220-27.
SSRIEscitolopramCitalopramParoxetineFluoxetineSertraline
OPIOIDSFentanylMethadoneMeperidineDextromethorphanTramadol
SNRIDuloxitineVenlafaxineMilnacipran
5 HT3 ANTAGONISTSOndansetronGranisetron
Herbs GinsengSt John’s Wort
ANTIDEPRESSANTSAmitryptiline, Imipramine, Clomipramine, Desipramine, Trazodone, Nefazodone
Serotonin Re-Uptake Inhibitors
SSRI Selective Serotonin Re-uptake Inhibitors SNRI Serotonin Noradrenalin Re-Uptake Inhibitors