Terry Altringer, Pharm.D . Clinical Pharmacy Coordinator – Trinity Health

1. From Brain to Bedside: Incorporating fundamental pharmacology-related topics into practical patient care Terry Altringer, Pharm.D. Clinical Pharmacy Coordinator – Trinity Health Residency Program Director – Trinity Health Adjunct Preceptor – NDSU College of Pharmacy

2. Disclosure Statement • The presenter has no actual or potential conflicts of interest in relation to this presentation

3. Objectives • Review the general principles of safe and accurate drug administration • Describe how basic pharmacologic and pharmacokinetics parameters impact bedside care • Discuss common patient specific variables that affect the actions of drugs • Discuss how to safely monitor patients after drug administration • Review the importance of patient-directed medication education

4. Secondary Objectives • To provide an overview of medication safety • To encourage you to continue to learn and practice ways to improve the safety of medication use

5. The Unthinkable Day https://www.youtube.com/watch?v=XEbf9bliOus

6. 3 month old male admitted with respiratory distress most likely due to bronchiolitis. Staff Nurse: “I received report at 7 p.m. and was reviewing the orders and saw that he had some medications due.” Both Reglan and Digoxin were due at 2000. I went to the medication room and prepared the medications. Story: Admission of a patient…

7. “I checked the online formulary and confirmed the Reglan and Digoxin were ordered in the correct dose and route. I checked the labels on the syringe and double checked the dose against the order on the medication administration record. I took the medication to the bedside.” Looked meds up on the online formulary. Checked the dose. Checked the med. Took labeled syringes to patients room. “I saw that he had some medications due…”

8. Next steps... Open the patient’s MAR to do the 5 R’s What questions do you have? What are the clinical indications for these two meds in this infant? Prepare to barcode scan patient ID band and medications. “Preparing to administer the medication…”

9. Mom said, “At home I give the Reglan, the other medication must be a new one.” I told her it was ordered by the doctor for the baby’s heart. Mom said, “Is there something wrong with his heart?” “I told mom I was giving Digoxin and Reglan..”

10. I said “Let me double check his chart.” I looked at the chart. The patient was here for respiratory distress. I did not see anything about a heart problem. I called the resident who reported, “I do not know of any heart problems in this patient.” I called my charge nurse. The charge nurse called the senior resident who said the child had no cardiac issues and should not have an order for Digoxin. Turns out the order was electronically placed in the wrong chart. “What if mom had not been there?” Mom said “Is there something wrong with his heart?”

11. 21st Century Nursing

12. The Basic Medication Management Process Nursing’s Role Last Line of Defense for Patient (26-32% of medication errors)

13. The “Real” Medication Management Process

14. Why understanding medication safety matters • 82% of Americans take at least 1 medication, 29% take >5 • In 1999; 44,000–98,000 deaths occurred each year due to medical mistakes. (IOM Report) • Every year medication errors injure at least 1.5 million Americans and cause 7,000 deaths. • Adverse drug events (ADEs) cause more than 1 million ED visits and 280,000 hospitalizations annually • ADEs comprise the largest single category of adverse events experienced by hospitalized patients, accounting for about 19 percent of all injuries • Increased morbidity, mortality, prolonged hospitalization, and higher cost

16. Medication Error (ME): Any mistakes occurring in the medication use process, regardless of whether an injury occurred or whether the potential for injury was present. Adverse Drug Event (ADE): An injury resulting from medication use, including physical harm, mental harm, or loss of function. • Adverse Drug Reaction (ADR), or non-Preventable ADE: Any ADE that occur due to pharmacological properties of the drug. Potential ADE (aka, Near Miss or Close Call): Medication errors that pose a significant risk but do not cause harm to a patient. Preventable ADE (pADE):ADEs resulting from a medication error that can be avoided.

17. Causes of Fatal Medication Errors • Among fatal medication errors, the Institute of Medicine (IOM) identities 3 main categories: • Human factors • Communication mistakes • Name confusion (LASA) • More specifically • Performance deficits (29.8%) – e.g., IV instead of IM • Knowledge deficits (14.2%) – drug-drug interaction • Miscalculation of dose (13%) – decimal placement Account for 90% of all errors

18. Which patients are most at risk of medication error? • Patients on multiple medications (polypharmacy) • Patients with another condition, (e.g. heart failure, renal impairment, pregnancy) • Patients who cannot communicate well • Patients who have more than one doctor • Patients who do not take an active role in their own medication use • Vulnerable populations (Newborn, children, geriatrics, impaired)

19. In what situations are staff most likely to contribute to a medication error? • Inexperience • Rushing • Doing two things at once – “multitasking” • Interruptions • Fatigue, boredom, being on “automatic pilot” leading to failure to check and double-check • Lack of checking and double checking habits • Poor teamwork and/or communication between colleagues • Reluctance to use memory aids - ?Pride

20. Types of Medication Errors • Wrong patient • Wrong drug • Wrong route • Wrong time • Wrong dose • Omitted dose • Wrong dosage form • Wrong diluent • Wrong strength/concentration • Wrong infusion rate

21. Ways to prevent medication errors • Know the patient • Know the drug(s) • Communication (SBAR) – [60% of sentinel events] • Drug packaging & labeling • Double-check high alert medications • Storage, stock, standardization, and distribution • Drug device acquisition, use, and monitoring • Environmental factors • Staff education • Patient education • Quality processes and risk management

22. Application of Pharmacology in Nursing Practice • Your responsibilities with regard to medications extend far beyond the Rights of Drug Administration. • Your medication knowledge has a wide range of practical applications in patient care and patient education. • You are part of the healthcare team that contributes to maximum patient benefit and minimum harm. • Application should be directed at individualized treatment.

23. General Principles of accurate drug administration Five Rights • Right patient • Right drug • Right dose • Right route • Right time

24. 5 Rights of Medication Administration Right Patient: • Open the correct patient’s Chart/MAR. • Look at the ID Band. • Barcode scan. • Do I have the correct patient?

25. 5 Rights of Medication Administration Right Medication: • Is this the right medication for the right patient? • Meds are located: • Patient specific bin or carts in the medication room • Locked medication alcoves in patient’s room • Automated Dispensing Cabinets (Pyxis, Omnicell) • Know the clinical indication for this patient to be receiving this medication. Why does this specific patient need this specific medication?

26. 5 Rights of Medication Administration Right Dose: • The ordered dose needs to match the dose on the medication label. • Is the dose correct for the weight of the child, if applicable? • Is the dose correct for the clinical indications and route?

27. 5 Rights of Medication Administration Right Route: • Know the correct route of administration: • Oral • Enteral • NG [nasogastric tube], GT [gastrostomy], JT [jejunostomy] • Parenteral • IV [intravenous], IM [intramuscular], SQ [subcutaneous] • Rectal • Intradermal • Transdermal • Transmucosal

28. 5 Rights of Medication Administration Right Time: • Is the medication due at this time? Check to see when it was last given. • Ensure the order has not changed which will impact the time it is due.

29. Key Reminder • The physician order and the corresponding eMAR/MAR entry are the sole source of truth. • Do not rely on other forms of secondary information such as: • Handheld barcode administration device • Notes from a colleague. • Always check the medical record!

30. Develop checking habits • Remember, computerized systems still require checking! • If you always check it will become a habit! • Some useful maxims … • Unlabeled medications should never be administered. • Never administer a medication unless you are 100% sure you know what it is.

32. Legal Responsibilities • Nurse is legally responsible for safe and accurate administration of medications • Nurse is expected to have sufficient drug knowledge to recognize and question erroneous orders

33. Encourage patients to be actively involved in their care! • When prescribing a new (or any) medication provide patients with the following information: • Name and purpose of medication • Common side-effects • Teach-back is a good way to validate patient understanding. • Allow time for questions.

34. General Principles of Drug Therapy • Expected benefits should outweigh potential adverse effects • Drug therapy should be individualized • Drug effects on quality of life should be considered in designing a drug therapy regiment

35. So let’s tackle some technical aspects

36. Pharmacokinetics https://www.youtube.com/watch?v=IOf-z0D1mHk

37. Finer PK Points Worth Noting ** Enteric Coated: Designed to release their content in the small intestine – not in the stomach. ** Sustained Release: Oral formulations designed to release their contents slowly, thereby permitting a longer interval between doses. These formulations should generally not be crushed, chewed or opened. Check with pharmacy.

38. A quick word about half-life (t ½) • Defined as the time required for the amount of drug in the body to decline by 50%. • Drugs that have a short half-life must be administered more frequently than drugs with longer half-lives (most of the time). • When drugs are administered repeatedly, their levels will gradually rise and reach a “steady state” plateau. • The time to reach “steady state” is equivalent to about 4-5 half-lives. • When a drug is discontinued, most (~94%) will be eliminated over 4-5 half-lives. • Both the time it will take for a drug to be effective, and the time it will take for it to leave the body completely, depend on a drug's half-life.

39. Half-life examples • Drugs with short half-lives will wear off quickly. • If the half-life is short and you want to keep the concentrations in your system steady, you have to take the drug every half-life. • The problem with drugs with really long half-lives is that they build up in the body and can get to really high concentrations, even if you are only taking them once per day. • For example, Prozac can still be in your system 6 weeks after you take the last dose.

40. Pharmacokinetics (PK)Age-related variation • General principles: • Premature infants are not the same as adolescents • Children are not little adults • Infants and geriatric patients are more sensitive to drugs than adults and are therefore more prone to adverse reactions

41. Pediatric Patients: Stages & Definitions • “Pediatrics” broadly encompasses all patients younger than age 16 years of age. • Many organs and functions are immature at birth.

42. Age-related PK variation- Pediatrics

43. Drug Therapy in Pediatric Patients:Pharmacokinetics in Neonates and Infants • Babies under the age of one year are “more sensitive” to drugs • Immaturity of organs puts neonates & infants at risk for: • more intense, more prolonged responses • increased risk of adverse effects due to kinetics • Age-related unique adverse effects • Example: kernicterus • At the age of 1 year, most pharmacokinetic parameters in children are similar to those of adults

44. Age-related PK variation - Geriatrics

45. Drug-Drug Interactions • Too many to even begin to discuss. • Look them up or consult with pharmacy

46. Drug-Solution Compatibility

47. Drug-Solution Compatibility • Because drugs can interact in solution, never combine two or more drugs in the same container or IV line unless you are certain (with evidence) that a direct interaction will not occur. • Pharmacists routinely use Trissel’s or King’s Guide for compatibility info. Don’t be afraid to call!

48. Drug-Food Interactions • Food may reduce the rate or extent of drug absorption (orally administered). • For some drugs, food may increase the extent of absorption (e.g., grapefruit juice). • Drugs may increase drug toxicity. • ‘On an empty stomach’ typically means to take the drug 1 hour before or 2 hours after a meal.

49. Practical Aspects of Drug Safety – Some Parting Thoughts • As previously mentioned, nursing responsibilities with regard to medication administration extend far beyond the Rights of Drug Administration. • Drug therapy application for the nurse should center around individualized treatment for each patient. • You are the patient’s last line of defense. • Never leave medications unattended. • Check and double check. • Listen to your instinct. Ask if in doubt. • Listen to the family.

50. The 5 C’s of a Healthcare Culture of Safety? • Competence • Communication • Collaboration and Coordination • Compassion