Assessment of learning by emergency medicine residents and pharmacy students participating in a poison center clerkship.

An AAPCC-designated poison center developed and validated an objective testing instrument to evaluate learning during a poison center clinical rotation for 2nd-year emergency medicine residents and 5th-year pharmacy students. The examination contained multiple-choice, true-false, and fill-in questions pertaining to basic clinical toxicology. A pretest was administered prior to the rotation and a post-test was administered upon completion of the rotation. Overall pre-test mean was 56.2%; physician pre-test mean was 73.8%, and student pre-test mean was 43.9%. Overall post-test mean was 78.7%; physician post-test mean was 85.7%, and student post-test mean was 81%. Pre-test scores ranged from 21 to 86% for the group, and post-test scores ranged from 68 to 96%. The mean difference in pre-test to post-test score was 26.9%. These data suggest that a poison center rotation can result in significant increases in post-test scores in comparison to pre-test scores.

Computer-guided academic detailing as part of a drug benefit program.

A service for identifying opportunities for drug cost savings in managed care plans and intervening by giving drug information to physicians is described. A clinical pharmacy company developed a computerized drug-use-review program to (1) identify and track variances in prescribing from drug-use criteria, (2) formulate plans for correcting the variances, and (3) document the impact of those interventions on drug costs. The software program weights prescriptions claims data against drug-use criteria to identify opportunities to save money. Savings opportunities for drug costs are defined as the net difference between the cost of the prescription claim and the lower, criteria-based cost. Episodes of potential savings are grouped by variables such as drug, physician, patient, and pharmacy, and each group is characterized by its total potential for cost savings. The groups are ranked to identify drug therapy problems that most contribute to the cost of medication misuse to the client. Pharmacists counsel identified physicians and enter the responses into a database for economic analyses. From September through December 1993, the software program was used to review 167,684 prescription claims totaling $4,368,576 in drug expenditures for enrollees in Pennsylvania's Pharmaceutical Assistance Contract for the Elderly program. Potential drug cost savings totaling nearly $280,000 were identified. Academic detailing by the company's pharmacists resulted in a saving in drug costs of more than $12,000 per month for the first three months after the detailing. Pharmacists at a clinical pharmacy company decreased drug costs for a managed care organization by using a software program to identify the drug costs with the greatest potential for savings and the physicians associated with those costs; the physicians were targeted for academic detailing.

Anaphylactoid reaction following ketorolac tromethamine administration.

OBJECTIVE: To report a case of an anaphylactoid reaction to injectable ketorolac tromethamine in a patient with no prior history of allergies or risk factors associated with nonsteroidal anti-inflammatory drug-induced hypersensitivity reactions. CASE SUMMARY: A 37-year-old man without a significant medical history presented to an emergency department with vague, dull, left-sided chest pain. Myocardial infarction was ruled out based on an unremarkable electrocardiogram, chest X-ray, and laboratory data that were within normal limits. Sublingual nitroglycerin 0.4 mg, magnesium/aluminum hydroxide gel 30 mL, and intravenous ranitidine 50 mg were administered without resolution of symptoms. Ketorolac tromethamine 60 mg was administered intramuscularly with resolution of symptoms. The patient was discharged; however, within 30 minutes, he returned to the emergency department with facial swelling, shortness of breath, and chest tightness. Multiple doses of aerosolized albuterol and intravenous methylprednisolone and diphenhydramine were administered, resulting in a slight improvement of symptoms. The patient was admitted for a complete cardiac evaluation that proved negative. The allergic symptoms resolved and the patient was discharged without medication after a three-day hospitalization. DISCUSSION: Ketorolac tromethamine is the first injectable nonsteroidal antiinflammatory drug approved for short-term pain management. A review of the literature revealed no similar cases of anaphylactoid reaction. CONCLUSIONS: Healthcare professionals must be aware of the potential risks of anaphylactoid reactions, especially in light of the increased use of injectable ketorolac in the ambulatory setting and availability of the oral formulation.

Drug-related emergency department visits and hospital admissions.

The incidence and causes of drug-related hospital admissions and visits to an emergency department were evaluated. A retrospective chart review was conducted to identify drug-related visits and admissions for all patients who visited the emergency department of a 517-bed tertiary-care institution during a four-month period. Drug-related illnesses were classified as adverse drug reaction (ADR), overdose or abuse, noncompliance, drug interaction, or toxicity. Patient data included demographic characteristics, medication history, serum drug concentrations, length of hospital stay, and hospital admission charges. Of 10,184 patients who visited the emergency department, 293 (2.9%) had drug-related illnesses; 71 (24%) of these patients were admitted. The drug classes most commonly involved were drugs of abuse (23.2%), anticonvulsants (17.1%), antibiotics (12.6%), respiratory drugs (8.9%), and pain medications (8.9%). The most common category of drug-related illness was overdose or abuse (35%) followed by noncompliance (28%), ADR (28%), toxicity (8%), and drug interaction (1%). The average length of stay for patients who were admitted was 5.8 days, and the average cost of admission was $8888. Drug-related illnesses accounted for 2.9% of hospital admissions and visits for patients in the emergency department. The most commonly identified drug-related illnesses were overdose or abuse, noncompliance, and ADRs; the drug classes most commonly implicated were drugs of abuse, anticonvulsants, and antibiotics.

Accidental childhood death from diphenhydramine overdosage.

A 15-month-old boy presented to an emergency department with tonic clonic jerking of all extremities and dancing eye movements. A history of instant coffee ingestion was obtained at that time. However, a routine blood analysis and toxicology screen showed a diphenhydramine level of 1.0 mg% (lethal, 0.5 mg%). Generalized tonic clonic seizures continued despite conventional therapy. A continuous thiopental infusion was used to control his seizure activity. This child never regained consciousness and was pronounced dead 7 days postingestion.