Safety Considerations and Guideline-Based Safe Use Recommendations for "Bolus-Dose" Vasopressors in the Emergency Department.

The use of intermittently administered doses of vasopressors to correct hypotension in the emergency department (ED), commonly referred to as bolus-dose pressors, push-dose pressors, Neo-sticks, or phenyl sticks, has been widely advocated outside of the traditional printed medical literature. No outcomes data of this practice exist to demonstrate benefits over traditional continuous infusion of vasopressors. Use of bolus-dose vasopressors in the ED setting raises a number of patient safety concerns, and misuse and errors in the preparation and administration of bolus-dose vasopressors may result in patient harm. A systems-based approach should be implemented to maximize safety and patient benefits if bolus-dose vasopressors are used. This article discusses the wide range of issues to consider when evaluating the role of bolus-dose vasopressors in the ED and provides recommendations based on current safe medication practices guidelines.

Interaction of vitamin K antagonists and trimethoprim-sulfamethoxazole: ignore at your patient's risk.

The aim of the study was to summarize available literature regarding the interaction between vitamin K antagonists (VKAs) and trimethoprim-sulfamethoxazole (co-trimoxazole, TMP-SMX), and to provide recommendations for managing patient risk from this interaction. Data sources were English-language publications in the medical literature and Internet databases. Relevant publications that directly or indirectly addressed the VKA-TMP-SMX interaction were selected and reviewed. The mechanism of the VKA-TMP-SMX interaction, frequency of concurrent use, effect on international normalized ratio (INR), increased risk of bleeding, and strategies for risk reduction are summarized. The concurrent use of VKA and TMP/SMX rapidly and consistently raises INR and is associated with a two- to five-fold increase in bleeding. Concurrent use of VKA and TMP-SMX should be avoided when possible. When VKA and TMP-SMX are co-prescribed, VKA dose reduction is usually required. Patient education as well as early and frequent INR monitoring is recommended to reduce risk from this interaction.

Medication related nausea and vomiting in palliative medicine.

There are multiple potential states and/or symptoms that may occur in the palliative care population including: pain, nausea/vomiting, fatigue, anorexia, dyspnea, hiccups, cough, constipation, abdominal cramps/bloating, diarrhea, pruritis, depression/anxiety, dysphagia and sleep disturbances. Some of this may be the direct result of medications or drug-drug interactions from agents prescribed to treat the medical conditions that the patient has. Medication-related nausea and vomiting (MRNV) is a significant problem in palliative medicine that is reasonably common likely due to the multiple medications that these patients are often taking.

Analgesic prescribing errors and associated medication characteristics.

UNLABELLED: Medication errors involving analgesics, including mistakes in prescribing, are a major contributor to suboptimal therapeutic outcomes and preventable adverse patient events. A systematic evaluation of 2,044 prevented (near-miss) analgesic prescribing errors detected in a teaching hospital was performed to better understand these errors and contributing error-prone analgesic medication characteristics. The overall detected error rate was 2.87 errors per 1,000 analgesic orders, with the error rate more than twice as high in pediatric patients than in adults. Error rates varied widely between drugs, dosage forms, and routes of administration, but there was general consistency of error rates within drug groups with similar characteristics. Commonly prescribed medications were associated with the most errors, but less frequently prescribed agents had higher error rates. A number of factors were found to contribute to errors, and the following characteristics contributed to 40% of errors: availability in dose forms for multiple routes of administration; modified dosage forms; atypical dosage regimens; sound-alike drug names; and analgesics used on an ongoing scheduled basis. PERSPECTIVE: Identifiable analgesic product characteristics and uses are associated with higher risk for errors. The findings of this study can guide patient and caregiver education, and can be incorporated into medication safety strategies to reduce patient risk from analgesic errors.

The VHA New England Medication Error Prevention Initiative as a model for long-term improvement collaboratives.

BACKGROUND: Quality improvement collaboratives (QICs) are a widely applied strategy for implementing change in health care organizations. Alternative collaborative methodologies were compared to gain insight into the elements important for QIC success. METHODS: A modified version of a previously described QIC evaluation tool was used to assess the methods and characteristics of the Medication Error Prevention Initiative (MEPI) and to compare MEPI with two other long-term ongoing QICs--the Vermont-Oxford Network's Neonatal Intensive Care QIC and the Northern New England Cardiovascular Disease Study Group, and the shorter-term Breakthrough Series QICs of the Institute for Healthcare Improvement (IHI). RESULTS: The modified QIC assessment tool was a useful framework for QIC assessment and comparison. The MEPI differed in scope of topic, team members, and the method for learning about and making improvements. CONCLUSIONS: Long-term QIC methods such as those used by MEPI may be particularly applicable when QICs address broad, complex, comprehensive, or organizationwide improvement needs.

Update on prescribing errors with HAART.

Medication-prescribing errors associated with HAART may lead to treatment failure, development of resistance, or drug toxicity. Reports have described HAART-related medication-prescribing errors; the causes of these errors are often multifactorial and include lack of knowledge about HIV treatments, complexity of regimens, and sound-alike/look-alike names of medications. Clinicians caring for HIV-infected patients should be aware of the potential for prescribing errors associated with HAART and employ strategies to prevent them.

Using the ISMP Medication Safety Self-Assessment to improve medication use processes.

BACKGROUND: The 194-item Institute for Safe Medication Practices (ISMP) Medication Safety Self-Assessment for hospitals is being used by a 21-hospital collaborative as a framework for understanding, evaluating, and systematically implementing medication use system safety improvements. METHODS: The results of the self-assessment were used to prioritize and organize the review of medication use processes, in which each self-assessment-defined "representative characteristic" is reviewed in detail, and "best implementation practices" for the characteristic are established. The collaborative concurrently identifies educational needs and develops tools to assist organizations in implementing improvements. RESULTS: By December 2002 participating organizations had implemented a wide variety of medication safety improvements. Collaborative member scores for the self-assessment increased approximately 20% during the initial assessment when the self-assessment was repeated by members in the second quarter of 2002. SUMMARY: Participant progress in improving medication safety practices is supportive of collaborative methods and the value of completing the ISMP self-assessment, expanding on the knowledge gained, developing effective implementation tools, and systematically applying lessons learned.

Systematic steps to diminish multi-fold medication errors in neonates.

Tenfold and other multiple-of-dose errors are particularly common in the neonatal intensive care unit (NICU), where the fragility of the patients increases the potential for significant adverse outcomes. Such errors can originate at any of the sequential phases of the process, from medication ordering to administration. Each step of calculation, prescription writing, transcription, dose preparation, and administration is an opportunity for generating and preventing medication errors. A few simple principles and practical tips aimed at avoiding decimal and other multiple-dosing errors can be systematically implemented through the various steps of the process. The authors describe their experience with the implementation of techniques for error reduction in a NICU setting. The techniques described herein rely on simple, inexpensive technologies for information and automation, and on standardization and simplification of processes. They can be immediately adapted and applied in virtually any NICU and could be integrated into the development of computerized order entry systems appropriate to NICU settings. Either way, they should decrease the likelihood of undetected human error.

Tenfold medication dose prescribing errors.

BACKGROUND: Tenfold errors in medication dosing continue to occur despite being a well-recognized risk, particularly to pediatric patients. Few systematic evaluations of the characteristics and causes of tenfold medication dosage prescribing errors have been performed. OBJECTIVE: To identify and quantify the characteristics of tenfold medication dosage prescribing errors. DESIGN: Evaluation of 200 consecutively detected medication orders with tenfold errors in dosing in a 631-bed tertiary-care teaching hospital. MAIN OUTCOME MEASURES: Type, frequency, characteristics, causes, enabling factors, and potential for adverse effects of tenfold medication dosage prescribing errors. RESULTS: Two hundred cases of tenfold prescribing errors were detected over an 18-month period. Overdoses were prescribed in 61% of the cases and underdoses in 39% of the cases. Ninety (45%) of the errors were rated as potentially serious or severe; 19.5% of the errors ocurred in pediatric patients. Levothyroxine accounted for 19% of all errors. As a class, antimicrobials, cardiovascular agents, and central nervous system agents each accounted for > or =15% of errors. Errors were associated with multiple zeroes in the dose (45%), use of equations or calculations to determine dose (27% total cases, 92.3% of pediatric cases), dose amount less than 1 (25%), and expression of measure conversion (23%). The tenfold errors were produced by a misplaced decimal point in 87 cases (43.5%), adding an extra zero in 63 cases (31.5%), and omitting a zero in 50 cases (25%). Factors identified as enabling a tenfold error to be carried out as ordered were a wide dose range for the drug (76.5%), medication ordered and able to be given by injection (42%), ability to give ordered dose as < or =5 solid oral dosage forms (36%), and availability of an oral liquid dose form (15%). CONCLUSIONS: Prescribing of tenfold medication dose errors is common and is associated with identifiable risk factors. Implementing commonly recommended medication safety processes are likely to reduce risk to patients from such errors. This information should be considered in the development of strategies to prevent adverse patient outcomes resulting from such errors.

Prescribing errors involving medication dosage forms.

CONTEXT: Prescribing errors involving medication dose formulations have been reported to occur frequently in hospitals. No systematic evaluations of the characteristics of errors related to medication dosage formulation have been performed. OBJECTIVE: To quantify the characteristics, frequency, and potential adverse patient effects of prescribing errors involving medication dosage forms. DESIGN: Evaluation of all detected medication prescribing errors involving or related to medication dosage forms in a 631-bed tertiary care teaching hospital. MAIN OUTCOME MEASURES: Type, frequency, and potential for adverse effects of prescribing errors involving or related to medication dosage forms. RESULTS: A total of 1,115 clinically significant prescribing errors involving medication dosage forms were detected during the 60-month study period. The annual number of detected errors increased throughout the study period. Detailed analysis of the 402 errors detected during the last 16 months of the study demonstrated the most common errors to be: failure to specify controlled release formulation (total of 280 cases; 69.7%) both when prescribing using the brand name (148 cases; 36.8%) and when prescribing using the generic name (132 cases; 32.8%); and prescribing controlled delivery formulations to be administered per tube (48 cases; 11.9%). The potential for adverse patient outcome was rated as potentially "fatal or severe" in 3 cases (0.7%), and "serious" in 49 cases (12.2%). Errors most commonly involved cardiovascular agents (208 cases; 51.7%). CONCLUSIONS: Hospitalized patients are at risk for adverse outcomes due to prescribing errors related to inappropriate use of medication dosage forms. This information should be considered in the development of strategies to prevent adverse patient outcomes resulting from such errors.