Joshua Villarreal amp Jennifer Knutson Medication Errors Affect up to 60 of Emergency Department ED patients 1 Patanwala AE Warholak TL Sanders AB et al A prospective observational study of medication errors in a tertiary care emergency department ID: 271224
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Slide1
Pearls (and perils) of drug administration in the Emergency Department
Joshua Villarreal & Jennifer KnutsonSlide2
Medication Errors
Affect up to 60% of Emergency Department (ED) patients
1
Patanwala AE, Warholak TL, Sanders AB, et al. A prospective observational study of medication errors in a tertiary care emergency department.
Ann Emerg Med
. 2010;55:522-526.Slide3
Medication Errors
Errors occur during
Prescribing process: 82%
Administration process: 12% Transcribing and monitoring: 6%
1
Patanwala AE, Warholak TL, Sanders AB, et al. A prospective observational study of medication errors in a tertiary care emergency department.
Ann Emerg Med
. 2010;55:522-526.Slide4
The Eight Rights:
Start (or stop) medication
Right Patient
Right Route Right Drug Right DoseRight Time
Right Documentation
Right to Refuse
Right Response
Errors @ UWMC EDSlide5
Right Route: Epinephrine
Intramuscular
Anaphylaxis:
0.3 mg IM 0.3 mL of a 1:1000 solution
Intravenous
Pulseless cardiac arrest
1mg
IV Push
10 mL of a 1:10,000 solutionSlide6
Epinephrine
New Policy Approved at UWMC
For Acute Allergic Reaction:
Route should always be IMDose should always be 0.3mgConcentration should always be 1mg/mLSlide7
Right Drug: Immediate vs. Timed Release
Immediate release:
Drug absorption
not delayed beyond original pharmacokinetic profile
Immediate release (IR)Slide8
Right Drug: Immediate vs. Timed Release
Timed release
Prolong absorption: Longer dosing intervals & less drug level fluctuation
Sustained-release (SR)
Sustained-action (SA)
Extended-release (ER, XR, XL)
Timed-release (TR)
Controlled-release (CR)
Modified release (MR)
Continuous-release (
Contin
)Slide9
Right Drug: Immediate vs. Timed Release
Opioids
Oxycodone (IR, CR)
Morphine (IR, ER)Cardiovascular Metoprolol (IR, XL)Diltiazem (IR, CD)
Antidepressants
Bupropion (IR, SR, XL)
Venlafaxine (IR, XR)Slide10
Right Drug: Immediate vs. Timed Release
Drug
Peak
Pyxis
Oxycodone (immediate)
1-2 hours
YES
Oxycodone CR or OxyContin
4-5 hours
NO
Morphine IR
1 hour
NO
Morphine ER or MSContin
4 hours
YESSlide11
Right Drug: Sound Alike Medications
Metoclopramide vs.
Metoprolol
Benadryl vs.
Benazapril
Clonazepam vs. Clonidine
Methadone vs.
Mephyton
Dobutamine
vs. DopamineSlide12
Right dose: Sedation & Vasoactive Drips
Drip rate errors
Vasoactive drips
Epinephrine
mcg/kg/min
Norepinephrine
mcg/kg/min
Phenylephrine
mcg/kg/min
Dopamine
mcg/kg/min
Dobutamine
mcg/kg/min
Sedation
Propofol
mcg/kg/minSlide13
Right dose: Sedation & Vasoactive Drips
Why so confusing?
Units not universally standard
New providers
Drug information resources
mcg/kg/min vs.
mcg/minSlide14
Right dose: Sedation & Vasoactive Drips
ICU Drug information Sheets
Starting doses
Titration schedules
Drug administration pearls
Monitoring parameters
RED binders
Rooms 1-5
Contain ICU drug information sheets
Code carts
Side of cart
Drip mixing and dosingSlide15
Right dose: Sedation & Vasoactive Drips
ICU Drug information Sheets
Starting doses
Titration schedules
Drug administration pearls
Monitoring parameters
RED binders
Rooms 1-5
Contain ICU drug information sheets
Code carts
Side of cart
Drip mixing and dosingSlide16
Right dose: Sedation & Vasoactive Drips
ICU Drug information Sheets
Starting doses
Titration schedules
Drug administration pearls
Monitoring parameters
RED binders
Rooms 1-5
Contain ICU drug information sheets
Code carts
Side of cart
Drip mixing and dosingSlide17
Right dose: Sedation & Vasoactive Drips
ICU Drug information Sheets
Starting doses
Titration schedules
Drug administration pearls
Monitoring parameters
RED binders
Rooms 1-5
Contain ICU drug information sheets
Code carts
Side of cart
Drip mixing and dosingSlide18
Right dose: Sedation & Vasoactive Drips
ICU Drug information Sheets
Starting doses
Titration schedules
Drug administration pearls
Monitoring parameters
RED binders
Rooms 1-5
Contain ICU drug information sheets
Code carts
Side of cart
Drip mixing and dosingSlide19
Right Dose: Heparin
Multiple Concentrations:
1 unit/mL
10 unit/mL1,000 units/mL5,000 units/mLVarious infusionsVarious rates
Various TargetsSlide20
Right Time: Prostacyclin Infusions
Life-sustaining continuous infusions:
Treprostinil (Remodulin)
Epoprostenol (Flolan)
http://www.muschealth.com/ph/education/medications.htmSlide21
Prostacyclin Policies
For Patients who present with prostacyclin infusions:
!!!DO NOT INTERRUPT PROSTACYCLIN INFUSION!!!
!!!DO NOT INTERRUPT PROSTACYCLIN INFUSION!!!
!!!DO NOT INTERRUPT PROSTACYCLIN INFUSION!!!Slide22
Prostacyclin Policies
Inform ED Pharmacist of all patients requiring prostacyclin infusion
If no ED Pharmacist, inform inpatient pharmacy
Blood cultures from prostacyclin infusion line need to follow Prostacyclin Infusion PolicySlide23
Prostacyclin Policies
Resources for infusion management or infusion complications:
Stephanie Harrie Nolley, Pulmonary Vascular Nurse Coordinator
STAT nursesPharmacistsSlide24
Prostacyclin PoliciesOn UWMC Intranet, “Policies and Procedures”Slide25
Prostacyclin PoliciesUnder Patient Care Services, “Nursing Policies and Procedures”Slide26
Prostacyclin PoliciesSlide27
QuestionsSlide28
Sepsis + Antibiotics
Sepsis: every minute counts…
Start antibiotics immediately, but which one? And more than one?Slide29
Sepsis + AntibioticsSlide30
Sepsis + AntibioticsSlide31
Questions