MEDICATION ERRORS and INTERACTIONS – Things to keep in mind

1. TRAUMA MEDICATION ERRORS and INTERACTIONS – Things to keep in mind Linda E. Pelinka, MD, PhD, Medical University of Vienna, and Boltzmann Institute for Experimental & Clinical Traumatology Vienna, Austria, European Union

2. “Errors in judgement must occur in the practice of an art which consists largely in balancing probabilities.” Sir William Osler British Royal College of Physicians 1883 Physician in chief, Johns Hopkins Hospital 1888 Author of Principles & Practice of Medicine

3. 1 drug error per 133 anesthetics 7 drug errors/AP/year if 1% of errors resulted in injury… Every AP would harm 2 pts in a 30 yr career 1000 APs would harm 2000 pts Glavin RJ. Br J Anaesth 2010; 105/1: 76-82.

4. Anesthesia professionals in the OR are the only med personnel who Prescribe Secure Prepare Administer and Document medications… …a process of up to 41 steps. Martin DE, Penn State College of Medicine. APSF Consensus Conf. 2010

5. These steps usually occur within a very short time interval, …a process of up to 41 steps. typically without standardized protocols and often in a distracting environment. Martin DE, Penn State College of Medicine. APSF Consensus Conf. 2010

6. Key System Elements that influence medication use most • Poor lighting • Cluttered space • Noise • Interruption • Multi-tasking Grissinger M, Ann Meeting American Pharmacists Ass 2007, Atlanta, GA

7. Litigation related to Drug Errors in Anaesthesia: Analysis of Claims against the NHS in England 1995-2007 Cranshaw J et al. Anaesthesia 2009; 64: 1317-23.

8. 93 claims 62 drug administration errors 31 wrong drug >50% neuromuscular blockers 25 wrong dose >30% opioid overdose inclneuraxial route Cranshaw J et al. Anaesthesia 2009; 64: 1317-23.

9. Syringe swaps, Labeling, Routes of administration

10. Male, age 58, Syringe Swap Choosing between only 2 syringes, both known to contain high-risk drugs, the provider ASSUMED instead of reading the syringe label, before injecting the WRONG DRUG by the WRONG ROUTE.

11. Survey of AP Do you ever carry drugs in your pocket? Does every anesthesiologist you know carry drugs in a pocket? Do you think it’s safe to do so? 100% YES to all 3 questions Kulli JC, webmm.ahrq.gov

12. Medication Errors in Anesthetic Practice: Survey of 687 Practitioners Orser BA et al.Can J Anaesth 2001; 42/2:139-46. Most common error: administration of a muscle relaxant instead of a reversal agent. Most common contributing factors: Syringe swaps (70%), label misidentification (47%) Most anesthesiologists (98%) reported reading the ampoule label “most of the time”. Label color was an important secondary cue.

13. In 27 of 28 cases, swaps occur between SAME SIZE SYRINGES Fasting S, Gisvold SE. Can J Anesth 2000; 47/11: 1060-67.

14. Adverse Drug Errors in Anesthesia. Impact of Coloured Syringe Labels. Fasting S and Gisvold SE. Can J Anesth 2000; 47/11: 1060-67. Syringe swaps occurred most often between syringes of equal size. Neither large letters nor colour coding were a strong enough visual cue to prevent errors. Almost no swaps occurred between syringes of different sizes. Using one size of syringe for only one group of drugs might be a strong enough visual cue to reduce syringe swaps.

15. Most frequent Syringe Swaps FENTANYL intended SUCCINYLCHOLINE given NEOSTIGMINE intended SUCCINYLCHOLINE or NM BLOCKER given MIDAZOLAM intended SUCCINYLCHOLINE or NM BLOCKER given Abeysekera A et al. Anaesthesia 2005; 60: 220-27.

16. Litigation related to Drug Errors in Anaesthesia: Analysis of Claims against the NHS in England 1995-2007 Most common adverse outcomes: • Awake paralysis • Resp depression requiring ICU 15 errors resulted in severe harm or death Cranshaw J et al. Anaesthesia 2009; 64: 1317-23.

17. Drug Administration Errors: a prospective Survey from 3 South African Teaching Hospitals Hospitals A&C treat adults, hospital B peds. Response rates: A+C 48%, B 81% Most common errors, A+C: substitution. B: substitution & incorrect dose. Causes for amp & syringe swaps (substitution errors): 21% syringe misidentification, 37% AMPOULE LOOK-ALIKES. Llewellyn RL et al. Anaesth Intensive Care 2009; 37/1: 93-8.

18. Look-alike Drugs Cause Near Miss Ge Li, MD, PhD, Elgin IL. www.apsf.org/newsletters/html/2009/winter/13_lookalikes.htm To the Editor: I administered anesthesia to a 4 yr old, 15 kg girl for tonsillectomy and adenoidectomy. Because of the size of the tonsils, the surgeon requested 20 mg of dexamethasone iv. Glycopyrrolate was in the same drug tray, close to the dexamethasone vial.

19. Look-alike Drugs Cause Near Miss Ge Li, MD, PhD, Elgin IL. www.apsf.org/newsletters/html/2009/winter/13_lookalikes.htm I was to give 5 dexamethasone vials (4mg/vial). 5 glycopyrrolate vials (0.4mg/vial) would have been at least 10 times more than the max allowable dose. Luckily, I checked the label. I think this “look-alike” is something important and that every anesthesiologist and anesthetist should be aware of the similarity.

21. Amp/Vial Swaps • Similar very small writing on amp • Same manufacturer • Same size

22. Amp/Vial Swaps

23. Amp/Vial Swaps

24. Drug Error in Anaesthetic Practice: Review of 896 Reports from the Australian Incident Monitoring Study Database. Wrong route: The most significant factor of this section was the large number of errors associated with regional anesthesia, despite using the normal checks, including aspiration to check for blood. Abeysekera A et al. Anaesthesia 2005; 60: 220-27.

25. Local Anesthetics: Baricity, Concentration, Additives

26. Compatible Cross Connection The problem of cross-connection of anesthesia gasses recognized >50 years ago. Has been almost eliminated by mandated use of incompatible connectors for different gasses. Preventing catheter/tubing misconnections: Much needed help is on the way. ISMP Medication Safety Alert! Acute Care Edition. July 15, 2010; 15: 1-2.

27. Luer Connector System Shared by different tubing devices used in patient care, including • Periperal catheters • Epidural catheters • IV syringes Kulli JC, webmm.ahrq.gov

28. Prescribing Errors

29. Most Common Prescribing Errors 1 Lack of DRUG knowledge wrong dose wrong frequency Lack of PATIENT knowledge other meds drug interaction allergy

30. Key System Elements that influence medication use the most • Pt info: age, weight, diagnoses, allergies • Communication Grissinger M, Ann Meeting American Pharmacists Ass 2007, Atlanta, GA

31. Body Weight Over- & Underestimation, common cause of medication errors • Unfractionated heparin & LMWH • Glycoprotein IIb/IIIa receptor antagonists • Fibrinolytic agents (alteplase, tenecteplase) • Inotopes (dobutamine) • Vasopressors (dopamine, norepinephrine) • Vasodilators (nesiritide, nitroprusside) • Inodilator milrinone Cockroft DW and Gault MH. Prediction of Creatinine Clearance from Serum Creatinine. Nephron 1976; 16: 31-41.

32. Drugs most commonly misused by health care professionals 1)Insulin 4) Hydrocodone 5) Ibuprofen 6) Acetaminophen 7) Aspirin 2)Anticoagulants 3)Antibiotics Grissinger M, Ann Meeting American Pharmacists Ass 2007, Atlanta, GA

33. Creatinine Clearance Correct estimation is one of the most important factors in dosing • Enoxaparin • Eptifibatide • Tirofiban • Bivalirudin • Dofetilide • Sotalol Cockroft DW and Gault MH. Prediction of Creatinine Clearance from Serum Creatinine. Nephron 1976; 16: 31-41.

34. Top 5 of 355 drugs most commonly associated with errors Glavin RJ. Br J Anaesth 2010; 105/1: 76-82.

35. Claims involving Allergic Reactions • 65% • Previously KNOWN allergen • >30% Penicillin • 20% severe reaction • No lasting sequelae n=31 • 35% • Previously UNKNOWN allergen • 45% death • 40% cardioresp arrest CNS damage Cranshaw J et al. Anaesthesia 2009; 64: 1317-23.

36. Drug administration errors Abeysekera A et al. Anaesthesia 2005; 60: 220-7.

37. Most Common Prescribing Errors 2 MisCALCULATING Dose Calculation Error Decimal Point Misplacement

38. Drugs most commonly mispreparedby health care professionals NM BLOCKER prepared instead of neostigmin VECURONIUM dilution error: H20 w/o vec Morphine dilution error Abeysekera A et al. Anaesthesia 2005; 60: 220-27.

39. Litigation related to Drug Errors in Anaesthesia: Analysis of Claims against the NHS in England 1995-2007 Most common adverse outcomes: • Awake paralysis • Respiratory depression requiring ICU 15 errors resulted in severe harm or death Cranshaw J et al. Anaesthesia 2009; 64: 1317-23.

40. Although iatrogenic opioid overdosing is a recurrent error reported to the NRLS*, it seems rarely reported in the context of anesthetic care. *National Patient Safety Agency National Reporting & Learning Service Cranshaw J et al. Anaesthesia 2009; 64: 1317-23.

41. Most Common Prescribing Errors 3 MisUNDERSTANDING Misreading, use of Abbreviations

42. Letters & Numerals commonly confused Lavin LA, Prescribing Errors St Louis University APNursing Conference, 2012

43. Cursive Letters & Numerals commonly confused

44. Confused Drug Names 1 www.ismp.org, Institute for Safe Medication Practices

45. Dimenhydrinate and Diphenhydramine • Dimenhydrinate = DRAMAMINE • Diphenhydramine = BENADRYL • Both vials same color • Both have long names beginning with D • Both often stored beside each other in kit • Dimenhydrinate is an anti-emetic • Diphenhydramine is an anti-histaminic http://medicscribe.com/2010/05/medication-errors-epinephrine

46. Confused Drug Names 2 www.ismp.org, Inst. f. Safe Medication Practices * brand name

47. Confused Drug Names 3 * brand name www.ismp.org, Institute for Safe Medication Practices

48. Confused Drug Names 4 www.ismp.org, Institute for Safe Medication Practices

49. Drug Interaction

50. SEROTONIN = 5-HYDROXY-TRYPTAMINE