Clinical Pharmacist PICU RMCH Clinical Lecturer University of Manchester Patient A 612 Septic hypotensive Undiagnosed complex condition GDD GORD Congenital hyperinsulinaemia ID: 781427
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Slide1
Solutions for Confusion
Adam Sutherland
Clinical Pharmacist, PICU, RMCH
Clinical Lecturer, University of Manchester
Slide2Slide3Patient A
6/12Septic, hypotensive.Undiagnosed complex condition GDD GORD Congenital hyperinsulinaemia …and the rest!Monday0630Hypotensive 35/40Lactate 5pH 6.910640Loss of output
CPR commenced3 x adrenalineRx. adrenaline infusion 0.1microgram/kg/minA LIFE IN THE DAY…
Slide40700
CPR ongoingAdrenaline infusion commenced0710No response to adrenaline. Dose increased to 2microgram/kg/minRequest to remake infusion0715Day nurse and night nurse make infusion together:Day nurse finds adrenaline ampoules 1:10,000 in trayA LIFE IN THE DAY…TRANSCRIPTDay (D) “What volume of 1:10,000 did you draw up for that infusion?”Night (N) “Just what it said on the calculator”
D “Just that volume?”N “Yeah!”D “They’re different strengths…”N “No they’re not; they’re the same. They’re both adrenaline”D “No! This is ten times weaker than what’s on the chart…”
Slide5ROOT CAUSES
1) Human error in wrong concentration selection2) Service failure in training3) 20 minutes to commence infusionCONTRIBUTING FACTORSNursing preparation at the bedsideRule-of-SixA LIFE IN THE DAY…
Slide66mg/kg of drug X in 100ml of Diluent Y
Rate = 1ml/hrDose = 1microgram/kg/minTHE RULE OF SIX1980 vintage infusion pump
2014 infusion pump
Slide7THE RULE OF SIX
STRENGTHSQuick calculations at the bedside (?)Embedded into unit practicePredictable fluid loadBut still too much…?Simple to titrateAs long as you know what the concentration is in the syringe…
Slide8WEAKNESSESComplex prescribingComplex calculations for dilution and preparationRelies on impossibly accurate measurement and dilutionSlow to deliver from point of ordering
THE RULE OF SIX
Slide9To debunk the Rule of Six
To present potential benefits of standardisationPatient carePatient safetyUnit efficiencyWHY AM I HERE?
Slide10The rule of six CAUSES medication error
PrescribingCalculationDilutionAdministrationErrors are common, undetectable and CANNOT be overcomeParshuram 2003 - Opiate infusions in PICUWheeler 2007 - Inotropes in Adult ICUAllegaert 2011 - Paracetamol in NICUAguado-Lorenzo 2013 - Opiate infusions in NICU
Not negligent, just humanDEBUNKING THE RULE OF SIX
Slide11DEBUNKING THE RULE OF SIX
Ped
Crit
Care Med 2006; 7(3); 225
Slide12Parshuram C et al.Ped Crit Care Med 2003 31(10);2483
Causes of inaccuracy
Human eye measurements
Inadequate mixing
Use of concentrated solutions
DEBUNKING THE RULE OF SIX
Slide13DEBUNKING THE RULE OF SIX
Parshuram
et al. CMAJ 2008; 178(1);42
CMAJ 2008; 178(1): 2
Slide14DEBUNKING THE RULE OF SIX
Arch Dis Child
2013:98; 975
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What are the implications:Patient instability at infusion changeSlow response to new ordersPatient responseNursing preparationIs ongoing instability related to:Real instability of the patient ORBecause the infusion is the wrong strength
Slide17DEBUNKING THE RULE OF SIX
Recommendations for IV infusion safetyStandardisation (Roman 2005)Ready mixed ready to use containers (NPSA 2007)Longer running infusions (Apkon 2004)Electronic prescribingPre-programmed syringe drivers (maybe: Murdoch 2008 )Roman, N. (2005).
Dimensions of Critical Care Nursing, 24(6), 275–278.Apkon, M. (2004). Quality and Safety in Health Care, 13(4), 265–271. Murdoch, L (2008)British Journal of Nursing, 17(10), 630–6.
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Fluid load…
Paediatr child Health 2008 13(5):371
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REGULATORY ACTION
Slide20DEBUNKING THE RULE OF SIX
REGULATORY ACTION
Risk assessmentReady to use solutionsReducing ward-level manipulation
74 incidents in TWO years; 4 “serious harm”; 2 “death”
“Consider pre-filled syringes”
Slide21DEBUNKING THE RULE OF SIX
Borthwick et al. 2007; JICS 8(1): 92
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IF WE DON’T EFFECT CHANGE OURSELVES ON OUR TERMS SOMEONE ELSE WILL FORCE US TO DO IT ON THEIRS