Medication Prescribing Errors on a Surgery Service - Addressing the Gap with a Curriculum for Surgery Residents: A Prospective Observational Study.

OBJECTIVES: Educational interventions with proven effectiveness to reduce medication prescribing errors are currently lacking. Our objective was to implement and assess the effectiveness of a curriculum to reduce medication prescribing errors on a surgery service. METHODS: This was a prospective observational cohort study at a Canadian academic hospital without an electronic order entry system. A pharmacist-led medication prescribing curriculum for surgery residents was developed and implemented over 2 days (2 h/day) in July 2019. Thirteen (76%) out of 17 surgery residents contributed pre-implementation data, while 13 (81%) out of 16 surgery residents contributed post-implementation data. Medication prescribing errors were tracked for 12 months pre-implementation and 6 months post-implementation. Errors were classified as prescription writing (PW) or decision making (DM). RESULTS: There were a total of 1050 medication prescribing errors made in the pre-implementation period with 615 (59%) PW errors and 435 (41%) DM. There were a mean of 87.5 (SD = 14.6) total medication prescribing errors per month in the pre-implementation period with 51.3 (11.9) PW and 36.3 (6.0) DM errors. There were a total of 472 medication prescribing errors made in the post-implementation period with 260 (55%) PW and 212 (45%) DM errors. There were a mean of 78.7 (10.3) total medication prescribing errors per month in the post-implementation period with 43.3 (9.5) PW and 35.3 (4.2) DM errors. In the first quarter of the academic year, there were significantly fewer mean total errors per month post-implementation versus pre-implementation (77.7(12.7) versus 107.3(8.1); P = .035), with significantly fewer PW errors per month (40.7(13.2) versus 68.7(9.3); P = .046) and no difference in DM errors per month (37.0(2.0) versus 38.7(5.7);P = .671). There were no differences noted in the second quarter of the academic year. CONCLUSION: Medication prescribing errors occurred from PW and DM. Medication prescribing curriculum decreased PW errors; however, a continued education program is warranted as the effect diminished over time.

Medication Errors in Surgery: A Classification Taxonomy and a Pilot Study in Postcall Residents.

INTRODUCTION: The post-call state in postgraduate medical trainees is associated with impaired decision-making and increased medical errors. An association between post-call state and medication prescription errors for surgery residents is yet to be established. Our objective was to determine whether post-call state is associated with increased proportion of medication prescription errors committed by surgery residents in an academic hospital without a computerized physician order entry (CPOE) system. METHODS: This prospective observational study was conducted at a tertiary academic hospital between June 28 and August 31, 2017. It compared the proportion of medication prescription errors committed by surgery residents in their post-call (PC) and no-call (NC) states. A novel taxonomy was developed to classify medication prescription errors. RESULTS: Sixteen of twenty-one eligible residents (76%) participated in this study. Self-reported hours of sleep per night was significantly higher in the NC group compared to the PC group (6(4-8) vs 2(0-4) hours, P < 0.01). PC residents committed a significantly higher proportion of medication prescription errors versus NC residents (9.2% vs 3.2%; p=0.04). Decision-making and prescription-writing errors comprised 33% and 67% of errors, respectively. CONCLUSIONS: The post-call state in surgery residents is associated with a significantly higher proportion of medication prescription errors in a hospital without a CPOE system. Decision-making and prescription-writing errors could potentially be addressed by additional educational interventions.

Erythromycin, QTc interval prolongation, and torsade de pointes: Case reports, major risk factors and illness severity.

OBJECTIVES: Erythromycin is a macrolide antibiotic that is widely used for various infections of the upper respiratory tract, skin, and soft tissue. Similar to other macrolides (clarithromycin, azithromycin), erythromycin has been linked to QTc interval prolongation and torsade de pointes (TdP) arrhythmia. We sought to identify factors that link to erythromycin-induced/associated QTc interval prolongation and TdP. METHODS AND RESULTS: In a critical evaluation of case reports, we found 29 cases: 22 women and 7 men (age range 18-95 years). With both oral and intravenous erythromycin administration, there was no significant relationship between dose and QTc interval duration in these cases. Notably, all patients had severe illness. Other risk factors included female sex, older age, presence of heart disease, concomitant administration of either other QTc prolonging drugs or agents that were substrates for or inhibitors of CYP3A4. Most patients had at least two risk factors. CONCLUSIONS: On the basis of case report evaluation, we believe that major risk factors for erythromycin-associated TdP are female sex, heart disease and old age, particularly against a background of severe illness. Coadministration of erythromycin with other drugs that inhibit or are metabolized by CYP3A4 or with QTc prolonging drugs should be avoided in this setting.

Multifactorial QT Interval Prolongation and Takotsubo Cardiomyopathy.

A 71-year-old woman collapsed while working as a grocery store cashier. CPR was performed and an AED revealed torsades de pointes (TdP). She was subsequently defibrillated resulting in restoration of sinus rhythm with a QTc interval of 544 msec. Further evaluation revealed a diagnosis of Takotsubo Cardiomyopathy (TCM) contributing to the development of a multifactorial acquired long QT syndrome (LQTS). The case highlights the role of TCM as a cause of LQTS in the setting of multiple risk factors including old age, female gender, hypokalemia, and treatment with QT prolonging medications. It also highlights the multifactorial nature of acquired LQTS and lends support to growing evidence of an association with TCM.

Acquired long QT interval: a case series of multifactorial QT prolongation.

BACKGROUND: Acquired long QT (LQT) interval is thought to be a consequence of drug therapy and electrolyte disturbances. HYPOTHESIS: We characterize the potential effects of polypharmacy in a case series of acquired LQT and torsades de pointes (TdP) in order to determine whether multiple risk factors play a role in the development of LQT. METHODS: The case series consisted of 11 patients presenting to 4 tertiary care hospitals with LQT and ≥ 2 risk factors for developing LQT. Clinical characteristics, medications, electrolyte disturbances, and course in hospital were analyzed. RESULTS: Mean age was 49.1 ± 5.8 years. Eight patients were female. Four had hypertension, 1 had a history of dilated cardiomyopathy, and 1 patient demonstrated complete atrioventricular block. Average QTc interval at presentation was 633.8 ± 29.2 ms. Nine patients developed TdP. In 3, LQT was not initially detected and amiodarone was administered, followed by development of TdP. Patients were taking an average of 2.8 ± 0.3 QT-prolonging medications-an antidepressant in 6 cases and a diuretic in 8 cases. All patients had an electrolyte abnormality; 8 patients presented with severe hypokalemia (<3.0 mmol/L). Average serum potassium and magnesium were 2.82 ± 0.10 mmol/L and 0.75 ± 0.03 mmol/L, respectively. There were no deaths. CONCLUSIONS: This case series highlights the risks of polypharmacy in the development of LQT and TdP. It illustrates the importance of early detection of LQT in patients with multiple risk factors in ensuring appropriate treatment.

Multifactorial QT interval prolongation.

Acquired long QT interval has been widely reported to be a consequence of drug therapy and electrolyte disturbances. We describe two cases of multifactorial acquired QT interval prolongation and torsades de pointes. In the first case, the drugs venlafaxine, amiodarone and domperidone may have contributed to QT interval prolongation in a patient with hypokalemia and hypomagnesaemia. In the second case, QT interval prolongation occurred in a patient taking quetiapine and citalopram, and whose use of hydrocholorothiazide and history of chronic alcohol abuse likely contributed by rendering the patient hypokalemic. These cases highlight the potential risks associated with polypharmacy and demonstrate that though torsades de pointes is an uncommon arrhythmia, the combination of multiple factors known to prolong QT interval may precipitate this life-threatening arrhythmia.

Complete heart block following intentional carbamate ingestion.

Organophosphates and carbamate compounds are acetylcholinesterase inhibitors used as agricultural insecticides and represent a common cause of cholinergic toxicity. Cardiac manifestations of organophosphate and carbamate toxicity are described primarily from reports of organophosphate exposure and include sinus bradycardia, prolonged PR interval, sinus tachycardia, prolonged corrected QT interval and ventricular arrhythmias. Complete atrioventricular block has rarely been reported with insecticide poisonings. A case of complete heart block following carbamate ingestion is described and the importance of extended cardiac monitoring in these patients is emphasized.

Ventricular fibrillation triggered by marijuana use in a patient with ischemic cardiomyopathy: a case report.

BACKGROUND: A 60-year-old man presented to the emergency department with a left eye orbital rupture sustained during a fall due to syncope shortly after smoking more than his usual amount of marijuana. CASE PRESENTATION: The patient reported experiencing a shock from his implantable cardioverter-defibrillator (ICD) device prior to the loss of consciousness. There was no biochemical, electrocardiographic, or clinical evidence of ischemia. ICD interrogation revealed one episode of ventricular fibrillation which was appropriately sensed and treated with a single shock of 35 Joules. CONCLUSION: Although the cardiovascular effects of marijuana are usually well tolerated in young healthy users, its use may trigger life-threatening arrhythmias in patients with structural heart disease. To the best of our knowledge, this is the first report on a case of ventricular fibrillation triggered by marijuana use in a patient with an ICD.

Corrected QT interval prolongation after an overdose of escitalopram, morphine, oxycodone, zopiclone and benzodiazepines.

Escitalopram is the recently marketed S-enantiomer of the widely used antidepressant citalopram. Data from intentional overexposure to this medication are limited. Twelve-lead electrocardiogram (ECG) effects from racemic citalopram have been described; however, the present report is the first, to the best of the authors' knowledge, that describes all the reported abnormalities in a single patient receiving escitalopram. A 52-year-old man with a history of depression treated with escitalopram 10 mg/day, extended-release morphine 30 mg/day and zopiclone 15 mg/day was found unconscious at his home. He was known to have attempted suicide three weeks previously. Partially emptied bottles of escitalopram, morphine, oxycodone, zopiclone, lorazepam and diazepam were found close to the patient. He was transferred to the emergency department, where airway management and other supportive care were initiated. The patient was transferred to the intensive care unit. The initial 12-lead ECG demonstrated junctional rhythm at 48 beats/min, a wide complex escape (145 ms) with right bundle branch morphology and a prolonged corrected QT interval at 650 ms. Cardiac monitoring was undertaken. No ventricular arrhythmias or torsade de pointes were detected. No specific treatment for shortening the QT was implemented. Another 12-lead ECG performed 48 h later demonstrated sinus tachycardia with a normal corrected QT, normal PR interval and normal QRS duration. The effects of the overdose of escitalopram on the ECG and its interactions with other drugs are reviewed.