Improving the medication-use process for 23.4% sodium chloride.

PURPOSE: Results of a study to evaluate medication storage, distribution, and safety outcomes after addition of 23.4% sodium chloride to a hospital formulary and development of a novel distribution process incorporating safeguards allowing for urgent medication removal from an automated dispensing cabinet (ADC) are reported. SUMMARY: A retrospective review of 23.4% sodium chloride injection doses dispensed during a 38-month period was performed at an academic medical center to evaluate times from order entry to pharmacist verification, dispensing, and administration; adverse events related to dispensing or administration; and other outcomes. Seventy doses of 23.4% sodium chloride injection were administered to 60 patients during the study period. The mean times from order entry to pharmacist verification, medication removal from an ADC, and administration were 8, 25, and 43 minutes, respectively, when the ADC override function was not used. After 23.4% sodium chloride injection's addition to the ADC override list, 16 of 30 doses were removed "on override," with order entry performed retrospectively for 9 of these doses. There were no documented adverse events related to medication distribution and 2 adverse effects possibly related to medication administration. CONCLUSION: Novel storage and distribution processes for 23.4% sodium chloride injection were implemented at a large academic medical center to optimize safety related to the medication-use process. A retrospective review of 70 administered doses found the process of maintaining this medication in ADCs to be a safe and efficient method of storing and dispensing a high-alert medication.

Risk factors associated with bleeding after alteplase administration for pulmonary embolism: a case-control study.

STUDY OBJECTIVE: To identify risk factors associated with bleeding in patients who received alteplase for pulmonary embolism (PE), with a specific focus on risk factors available to the clinician at the time thrombolytics are being considered. DESIGN: Case-control study. SETTING: Large academic medical center. PATIENTS: Sixty-two adults with PE who were administered alteplase 100 mg over a 2-hour infusion period between January 2000 and October 2011; of these patients, 28 experienced major bleeding (case patients), and 34 did not develop major bleeding (control patients). MEASUREMENTS AND MAIN RESULTS: Risk factors for bleeding from alteplase were compiled from the U.S. product label and the literature. Multivariate logistic regression analysis was used to assess for risk factors independently associated with bleeding. Patients with major bleeding more frequently had recent major surgery (odds ratio [OR] 9.00, 95% confidence interval [CI] 1.01-79.99, p=0.039), an international normalized ratio above 1.7 (OR 13.20, 95% CI 1.54-113.52, p=0.008), and one or more risk factors for bleeding (OR 5.02, 95% CI 1.68-15.04, p=0.003). On multivariate analysis, one or more risk factors for bleeding (adjusted OR 5.74, 95% CI 1.78-18.55, p=0.004) and body weight (adjusted OR 1.18 for each 10 kg below 100 kg, 95% CI 1.01-1.37, p=0.035) were independently associated with major bleeding. Intensive care unit length of stay after alteplase administration was significantly longer in patients with major bleeding (median 2.2, interquartile range [IQR] 0.9-4.8) days versus 1.1 (IQR 0.4-1.9 days, p=0.028). CONCLUSION: Risk factors for bleeding that are available to clinicians at the time the decision is made to administer alteplase for PE are significantly associated with the occurrence of major bleeding; the odds of major bleeding in patients with one or more risk factors for bleeding were ~5 times higher than in patients without these risk factors. Thus clinicians should weigh these risk factors for bleeding against the perceived benefit of thrombolytic therapy when deciding to administer a thrombolytic in an individual patient with PE.