ABSTRACT
OBJECTIVE: Medical errors play a large role in preventable harms within our health care system. Medications administered in the ICU can be numerous, complex and subject to daily changes. We describe a method to identify medication errors with the potential to improve patient safety. DESIGN: A quality improvement intervention featuring a daily medication time out for each patient was performed during rounds. SETTING: A 12-bed Cardiac Surgical ICU at a single academic institution with approximately 180 beds. INTERVENTION: After each patient encounter, the current medication list for the patient was read aloud from the electronic medical record, and the team would determine if any were erroneous or missing. Medication changes were recorded and graded post-hoc according to perceived significance. RESULTS: This intervention resulted in 285 medication changes in 347 patient encounters. 179 of the 347 encounters (51.6%) resulted in at least one change. Of the changes observed, 40.4% were categorized as trivial, 50.5% as minor and 9.1% were considered to have significant potential impact on patient care. The average time spent per patient for this intervention was 1.24 (SD 0.65) minutes. CONCLUSIONS: A daily medication time out should be considered as an additional mechanism for patient safety in the ICU.
Subject(s)
Critical Care , Intensive Care Units , Medication Errors/prevention & control , Medication Therapy Management/standards , Drug-Related Side Effects and Adverse Reactions , Electronic Health Records , Female , Humans , Intensive Care Units/standards , Male , Medication Errors/statistics & numerical data , Quality Improvement , Time Factors , United StatesABSTRACT
Low cardiac output after orthotopic heart transplant (OHT) may be attributed to inadequate preload, vasodilation, and/or reduced inotropy. Inadequate preload because of an inferior vena cava (IVC) thrombus is a rare cause of low cardiac output and not frequently described in the literature. Although the use of prothrombin complex (PCC) has been associated with thrombus formation, its contribution to life-threatening IVC thrombosis has yet to be described. This case report describes the use of perioperative ultrasound in the diagnosis and management of a low cardiac output state induced by an IVC thrombus in an OHT recipient who received PCC.
Subject(s)
Blood Coagulation Factors/adverse effects , Cardiac Output, Low/diagnosis , Heart Transplantation , Venous Thrombosis/diagnosis , Blood Coagulation Factors/therapeutic use , Cardiac Output, Low/diagnostic imaging , Echocardiography , Humans , Male , Middle Aged , Tomography, X-Ray Computed , Vena Cava, Inferior/diagnostic imaging , Venous Thrombosis/chemically induced , Venous Thrombosis/diagnostic imagingABSTRACT
Anesthesiologists often administer medications through an IV catheter that is distal to a noninvasive blood pressure (NIBP) cuff. We report 2 cases where indigotindisulfonate (Indigo Carmine) was administered through an IV catheter distal to an NIBP cuff. NIBP cuff inflation after indigotindisulfonate administration resulted in diffuse limb discoloration distal to the NIBP cuff although the IV catheter remained completely within the intact vein. These cases suggest that administration of medications that have the same physical characteristics as indigotindisulfonate under the same conditions (i.e., proximal venous occlusion) could also result in an interstitial distribution of these drugs.
