Jerry Fahrni

Category: Medication Safety

  • Article: The costs of adverse drug events in community hospitals

    The article below appeared in the March 2012 edition of Joint Commission Journal on Quality and Patient Safety – yes, that’s a real journal. I couldn’t make this stuff up – Anyway, there’s nothing new here, we all know that ADEs are expensive. How expensive? Well, the bottom line is that “ADEs were associated with an increased adjusted cost of $3,420 and an adjusted increase in length of stay (LOS) of 3.15 days”. Depending on the number of ADEs your facility has you could easily use these numbers to justify the services of a pharmacist.

    The only problem with the information is that it’s from a 20-month period between January 2005 and August 2006. I hate to break it to you Joint Commission Journal on Quality and Patient Aafety, but that makes the information all but useless. Interesting, but useless.

  • Ambiguous and Dangerous Abbreviations article results in interesting comment

    There’s a little blurb in the March 2012 issue of Pharmacy Times about the dangers of using inappropriate abbreviations in prescriptions. The author gives a couple of good examples where the use of abbreviations resulted in errors. I’ve seen my fair share of crappy handwriting and liberal use of abbreviations during my career, and I almost always read articles that talk about the problem. I find them interesting.

    Anyway, there’s nothing particularly interesting about this article, but Mitch Fields, RPh left the following comment:

    Well, yet another article re: dangerous and ambiguous “pharmacy” abbreviations in a pharmacy journal. I’ve seen dozens such articles over the past 30+ years, and they all suffer from the same problem: they don’t belong in the journals of practitioners who READ prescriptions, they belong in the journals of the practitioners who WRITE prescriptions!

    That is one of the most logical things I’ve ever read. Mitch makes a great point.

  • Medscape application now available for the Kindle Fire

    I’m sure by now everyone has heard of the Kindle Fire. If not just know that it is the 7-inch color media device from Amazon based on the Android operating system. The device has been uber popular to this point. It’s difficult to tell how popular exactly, but one thing is for sure, you know a device has gained some ground by the applications that get developed for it.
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  • Failure to use “low concentration” alerts properly leads to errors [ISMP Safety Alert]

    When I read the headline in the most recent ISMP Medication Safety Alert! – Smart pump custom concentrations without hard “low concentration” alerts – I didn’t really get it. So what if a smart pump doesn’t stop you from programming “low concentrations”? Well after reading through the article, and the examples, it made perfect sense.

    Failing to employ available dose error-reduction software (DERS) as intended and to heed important clinical alerts are common contributors to these errors. In particular, the misuse of custom concentration options (i.e., user must fill in the concentration) that do not employ a hard (requires reprogramming) minimum concentration limit is a prime example. This issue contributes largely to preventable errors with smart pumps given the counterintuitive, inverse relationship between concentration and volume. More concentrated drugs require less volume to deliver a specified dose; less concentrated drugs require more volume to deliver a specified dose. When using “fill-in-the-blank” custom concentrations, the concentration must be programmed into the pump so it can calculate the volume needed to deliver the prescribed dose. If the programmed concentration is lower than the actual concentration in the infusion bag or syringe, the pump will deliver an overdose. If the programmed concentration is higher than the actual concentration in the bag or syringe, the pump will deliver an underdose. Without a hard minimum concentration limit, the former scenario has led to life-threatening events, such as those described below.

    Here’s a great example from the article that made the light bulb go off in my mind:

    A physician prescribed IV HYDROmorphone 20 mg/100 mL (0.2 mg/mL) to infuse at 2.5 mg/hour. In this hospital, the standard concentration for this infusion was 0.1 mg/mL, so the custom concentration of 0.2 mg/mL had to be entered into the smart pump. The nurse selected the custom concentration option then mistakenly entered 2.5 mg/100 mL as the concentration instead of 20 mg/100 mL. Given the erroneously programmed concentration of 0.025 mg/mL, the pump issued a soft (can be overridden) low concentration alert. The nurse overrode the warning, mistakenly believing the warning was inconsequential. Based on the erroneous concentration, the smart pump infused the drug at a rate of 100 mL/hour, while the intended rate was 12.5 mL/hour. The pump delivered the entire bag of HYDROmorphone 20 mg to the patient in 1 hour.

  • ADR death statistics for the US, 1999-2006 [article]

    Here’s an interesting article from the February 2012 issue of The Annals of Pharmacotherpy [Adverse Drug Reaction Deaths Reported in United States Vital Statistics, 1999-2006].1 The most commonly involved drug classes are no big surprise, but it was interesting to note that the incidence of ADR death changed with age, race, and urbanization. I suppose the increase in death rate for ADR with increased age and rural living isn’t that big of a surprise, but the differences among sex and race was unexpected. 

    ABSTRACT

    Current Issue Cover

    Background: Adverse drug reactions (ADRs) are an important source of morbidity and mortality during medical care.
    Objective: To examine the trends in mortality related to ADRs reported through the US vital statistics system since January 1999.
    Methods: Demographic characteristics of people reported as dying as a result of ADRs from 1999 to 2006 were evaluated. The National Mortality Statistics database was queried for International Classification of Diseases, Tenth Revision, codes Y40-Y59, which are specific for deaths due to adverse effects of drugs in therapeutic use. The data were subgrouped based on demographic factors to identify important trends. Crude rates were calculated based on incidents per 100,000 population. Odds ratios and 95% confidence intervals for subgroups were calculated by logistical regression.
    Results: During the 8-year study period 2,313,902,748 person years were evaluated and 2341 ADR-related deaths were identified. Annual rates ranged from 0.08/100,000 to 0.12/100,000, and rates increased significantly over time at a rate of 0.0058 per year. ADR deaths were significantly more likely in persons older than 55 years. The risk was greatest in those aged 75 years or older (OR 6.96, 95% CI 6.30 to 7.69). ADR deaths were higher among men than women. Rates varied by race and ethnicity and were highest among blacks (OR 1.38, 95% CI 1.23 to 1.54). Geographically, rates varied widely between states. Based on urbanization, rates were highest in extremely rural (non-core) areas (OR 2.05, 95% CI 1.76 to 2.38). The most common drug classes associated with death were anticoagulants, opioids, and immunosuppressants.
    CONCLUSIONS: ADR death rates have a clear association with age, race, and urbanization subgroups. Older individuals, males, blacks, and individuals residing in extremely rural areas experienced higher ADR death rates; these findings warrant further study to develop prevention strategies.

    1. Ann Pharmacother February 2012 vol. 46 no. 2 169-175

  • Don’t confuse Durezol and Durasal (S.A.L.A.D.)

    PharmQD: “FDA is alerting pharmacists and other health care professionals of potential injury due to confusion between the FDA-approved eye medicine Durezol (difluprednate ophthalmic emulsion) 0.05% and the unapproved prescription topical wart remover Durasal (salicylic acid) 26%.

    There has been one report of serious injury when a pharmacist mistakenly gave an eye surgery patient Durasal, the salicylic acid–containing wart remover, instead of the prescribed Durezol eye drops. Durezol is approved for treatment of inflammation and pain association with ocular surgery.”

    Seems like I’ve read about this mistake before. Being their typical efficient self, the FDA alert was issued on December 28, 2011, more than three months after ISMP alerted everyone.

    Some things you can do to prevent stuff like this from happening include (taken from a Pharmacy Times article):

    • Include both brand and generic names, along with indication, when prescribing look- or sound-alike drug names.
    • Spell out drug names that have been confused when accepting telephone orders. Require staff to write down the prescription and then perform a read back (and spell back for drugs that are known to cause confusion) of the complete prescription for verification.
    • Assign time to provide counseling to patients and/or caregivers, especially for new prescriptions.

     

  • DrugCite, a searchable database of drug side effects reported to the FDA

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  • High-Alert Medications Involved in Wrong-Drug Errors [Article]

    A recent article in Pharmacy Times outlines some interesting examples of Sound-Alike-Look-Alike-Drugs (SALAD) causing trouble in pharmacy. We’ve all seen them, and I’ve blogged about them before. Hydralazine and hydroxyzine represent a prototypical SALAD pair, but there are many others out there; ISMP’s list can be found here (PDF).
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  • Prevalence of medication administration errors in two medical units with automated prescription and dispensing [Article]

    From the Journal of the American Medical Informatics Association1. I was a little shocked by the number of errors, but as you can see in the abstract below, and in the title, the errors were during the administration phase of the medication use process. Seems a bit odd to look at medication errors during administration when talking about automated prescribing and dispensing. I’m sure there is an explanation in the full article. However that requires a subscription. Interesting nonetheless:

    Abstract
    Objective     To identify the frequency of medication administration errors and their potential risk factors in units using a computerized prescription order entry program and profiled automated dispensing cabinets.

    Design Prospective observational study conducted within two clinical units of the Gastroenterology Department in a 1537-bed tertiary teaching hospital in Madrid (Spain).

    Measurements Medication errors were measured using the disguised observation technique. Types of medication errors and their potential severity were described. The correlation between potential risk factors and medication errors was studied to identify potential causes.

    Results In total, 2314 medication administrations to 73 patients were observed: 509 errors were recorded (22.0%)—68 (13.4%) in preparation and 441 (86.6%) in administration. The most frequent errors were use of wrong administration techniques (especially concerning food intake (13.9%)), wrong reconstitution/dilution (1.7%), omission (1.4%), and wrong infusion speed (1.2%). Errors were classified as no damage (95.7%), no damage but monitoring required (2.3%), and temporary damage (0.4%). Potential clinical severity could not be assessed in 1.6% of cases. The potential risk factors morning shift, evening shift, Anatomical Therapeutic Chemical medication class antacids, prokinetics, antibiotics and immunosuppressants, oral administration, and intravenous administration were associated with a higher risk of administration errors. No association was found with variables related to understaffing or nurse’s experience.

    Conclusions Medication administration errors persist in units with automated prescription and dispensing. We identified a need to improve nurses’ working procedures and to implement a Clinical Decision Support tool that generates recommendations about scheduling according to dietary restrictions, preparation of medication before parenteral administration, and adequate infusion rates.

    1. J Am Med Inform Assoc. 2012 Jan 1;19(1):72-8. Epub 2011 Sep 2.

  • Wanna’ tell the FDA about drug shortages? Here’s how

    Here’s the contents of a email I received today from ASHP in regards to drug shortages and the FDA:

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    The Food and Drug Administration Wants to Hear How Drug Shortages Impact Patients

    The Food and Drug Administration has opened a comment period to gain insight about the causes and impact of drug shortages. The agency is seeking feedback as a follow up to a public workshop on the impact of shortages.

    You know first-hand the devastating effect that drug shortages are having on patient care.  Today, ASHP’s Drug Shortages Resource Center lists 208 shortages. That’s nearly the same number of shortages that were reported in all of 2010.

    This is your chance to speak up.

    Write a letter to the FDA that describes your experiences and challenges managing drug shortages.  Here’s what you should include:

    • Impact on patient care.  Share examples from your practice site, such as patients who’ve had to delay care or who’ve experienced adverse affects from second-line therapies.

    • Impact on pharmacy department operations: Discuss how the time spent researching availability of drug products and the redeployment of pharmacists from patient care roles affects the pharmacy department.

    Be sure to ask your colleagues in the pharmacy department as well as your nursing and physician colleagues to join you. Enlist your patients as well. Every voice counts!

    The deadline to submit comments is December 23, 2011. You can post comments on www.regulations.gov or send comments to the Division of Dockets Management (HFA-305), Food and Drug Administration, 5630 Fishers Lane, Rm.1061, Rockville, MD 20852.  See the Federal Register notice for more details.

    Your input and expertise are not only welcome, they are essential to achieving a solution to this critical issue.

    Use the resources below to familiarize yourself with ASHP’s messages on drug shortages.