Jerry Fahrni

Tag: Medication Errors

  • Warning labels on outpatient prescription vials not so great after all

    Everyone has seen them, I know you have. Those little colored labels that the pharmacy slaps on your bottle when you get a prescription: “May cause drowsiness”, “Avoid excess sun”, “Do not take aspirin products without doctor approval” and so on. There are a ton of them. I remember seeing them lined up in front of me when I was working retail. Sometimes it became a game to see how many you could fit on the bottle without covering up valuable information for the patient. I’ve also been in pharmacies where the warning labels were simply printed alongside the medication label.

    Well, it appears that this tradition may not be the best way to warn patients about potential issues with their medication. I mean, who really reads those things anyway?

    A small study recently published in the journal PLoS ONE took a look at these warning labels and determined that people really don’t pay attention. Not surprising.
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  • Medication reconciliation on an internal medicine unit in French hospital [Article]

    Interesting abstract from Presse Medicale (Paris, France) talking about medication reconciliation on an internal medicine unit in a French hospital. The authors found lots or discrepancies, which isn’t a surprise. They also found that pharmacists could help identify and correct many of the discrepancies, which also isn’t a surprise.

    Like many other articles I’ve read recently, this one is from data collected quite a while ago. The information was obtained from 61 patients between  June and October 2010. The article is from the March 2012 issue of the journal. I always marvel at how long it takes study results to get published.

  • 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.

  • A couple of really nice webinars from Pharmacy OneSource coming up

    I received an email today from Pharmacy OneSource outlining their upcoming webinars. Pharmacy OneSource has been offering great webinars for a while now, but these really piqued my interest.
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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.

  • 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.

  • Cool Pharmacy Technology–RevVac Syringe

    I suppose this could really be cool tech for nursing or lab, but I thought it was worth having a deeper look.

    The ReVac Retracting Safety Syring by Revolutions Medical “use a proprietary patented technology in which a vacuum causes the needle to retract into the barrel of the syringe or device after an injection is administered or blood is drawn.”

    According to the Revolutions Medical website “[t]he RevVac™ Safety Syringe and Phlebotomy (blood drawing) Device operate the same as a standard syringe and device. No additional training, skills, or procedures are necessary. The both products work on a vacuum principle, where pressing the plunger in them creates a vacuum. When the plunger reaches the bottom, the needle is captured. A further push on the plunger breaks the seal, and the needle retracts into the plunger barrel. The vacuum is maintained, so the needle cannot be removed from the plunger.”