MEDICATION ERRORS and INTERACTIONS – Things to keep in mind

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

TRAUMA

““Errors in judgement Errors in judgement

must occur must occur

in the practice of in the practice of

an art an art

which consists largely in which consists largely in

balancing probabilities.”balancing probabilities.”

Sir William OslerSir William OslerBritish Royal College of Physicians 1883British Royal College of Physicians 1883Physician in chief, Johns Hopkins Hospital 1888Physician in chief, Johns Hopkins Hospital 1888Author of Principles & Practice of MedicineAuthor of Principles & Practice of Medicine

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.

Anesthesia professionals in the OR are the only med personnel who

Martin DE, Penn State College of Medicine. APSF Consensus Conf. 2010

PrescribePrescribeSecure Secure PreparePrepareAdminister and Administer and Document medications… Document medications…

…a process of up to 41 steps.

These steps usually occur within a very short time interval,

Martin DE, Penn State College of Medicine. APSF Consensus Conf. 2010

typically without standardized protocols and often in a distracting environment.

…a process of up to 41 steps.

Poor lighting Cluttered space Noise Interruption Multi-tasking

Grissinger M, Ann Meeting American Pharmacists Ass 2007, Atlanta, GA

Key System Elements that influence medication use most

Cranshaw J et al. Anaesthesia 2009; 64: 1317-23.

Litigation related to Drug Errors in

Anaesthesia: Analysis of Claims

against the NHS in England 1995-2007


93 claims62 drug administration errors

31 wrong drug

>50% neuromuscular

blockers

25 wrong dose >30% opioid

overdose incl neuraxial route

Syringe swaps,

Labeling,

Routes of administration

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.

100% YES to all 3 questions

Kulli JC, webmm.ahrq.gov

Survey of AP

1.Do you ever carry drugs in your pocket?

2.Does every anesthesiologist you know carry drugs in a pocket?

3.Do you think it’s safe to do so?

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.

Medication Errors in Anesthetic Practice: Survey of 687 Practitioners

Fasting S, Gisvold SE. Can J Anesth 2000; 47/11: 1060-67.

In 27 of 28 cases, In 27 of 28 cases,

swaps occur swaps occur

between between

SAME SIZE SYRINGESSAME SIZE SYRINGES

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.

Adverse Drug Errors in Anesthesia. Impact of Coloured Syringe Labels.

Most frequent Syringe Swaps

FENTANYL intended

NEOSTIGMINE intended

MIDAZOLAM intended

SUCCINYLCHOLINE given

SUCCINYLCHOLINE or NM BLOCKER given


Abeysekera A et al. Anaesthesia 2005; 60: 220-27.


Most common adverse outcomes: Awake paralysis Resp depression requiring ICU

15 errors resulted in severe harm or death

Litigation related to Drug Errors in Anaesthesia: Analysis of Claims


Llewellyn RL et al. Anaesth Intensive Care 2009; 37/1: 93-8.

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.

Drug Administration Errors: a prospective Survey from 3 South

African Teaching Hospitals

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.

Look-alike Drugs Cause Near Miss

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.

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.

Look-alike Drugs Cause Near Miss

Similar very small writing on ampSimilar very small writing on ampSame manufacturerSame manufacturerSame sizeSame size

Amp/Vial SwapsAmp/Vial Swaps

Amp/Vial Swaps

Amp/Vial SwapsAmp/Vial Swaps

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.

Drug Error in Anaesthetic Practice: Review of 896 Reports from the

Australian Incident Monitoring Study Database.


Local Anesthetics: Baricity, Local Anesthetics: Baricity, Concentration, AdditivesConcentration, Additives

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.

Compatible Cross Connection

Preventing catheter/tubing misconnections: Much needed help is on the way. ISMP Medication Safety Alert! Acute Care Edition.

July 15, 2010; 15: 1-2.

Shared by different tubing devices

used in patient care,

includingPeriperal cathetersEpidural cathetersIV syringes


Luer Connector System

Prescribing

Errors

Most Common Prescribing Errors 1

Lack of

PATIENT knowledge

other medsdrug interaction

allergy

Lack of

DRUGknowledge

wrong dosewrong frequency

Key System Elements that influence medication use

the most

Pt info: age, weight, diagnoses, allergies

CommunicationGrissinger M, Ann Meeting American Pharmacists Ass 2007, Atlanta, GA

Cockroft DW and Gault MH. Prediction of Creatinine Clearance from Serum Creatinine. Nephron 1976; 16: 31-41.

Unfractionated heparin & LMWHGlycoprotein IIb/IIIa receptor antagonistsFibrinolytic agents (alteplase, tenecteplase)Inotopes (dobutamine)Vasopressors (dopamine, norepinephrine)Vasodilators (nesiritide, nitroprusside)Inodilator milrinone

Body Weight Over- & Underestimation,

common cause of medication errors

Drugs most commonly misused

by health care professionals


4) Hydrocodone

5) Ibuprofen

6) Acetaminophen

7) Aspirin

2)Anticoagulants

3)Antibiotics

1)Insulin

Creatinine ClearanceCorrect estimation is one of

the most important factors in dosing

Cockroft DW and Gault MH. Prediction of Creatinine Clearance from Serum Creatinine. Nephron 1976; 16: 31-41.

EnoxaparinEnoxaparinEptifibatideEptifibatideTirofibanTirofibanBivalirudinBivalirudinDofetilideDofetilideSotalolSotalol

Top 5 of 355 drugs most Top 5 of 355 drugs most commonly associated with errorscommonly associated with errors

Analgesics AntibacterialsBronchodilators Anti-anginals

Glavin RJ. Br J Anaesth 2010; 105/1: 76-82.Glavin RJ. Br J Anaesth 2010; 105/1: 76-82.

Claims involving Claims involving Allergic ReactionsAllergic Reactions n=31n=31

65%Previously KNOWN allergen>30% Penicillin20% severe reactionNo lasting sequelae

35%Previously UNKNOWN allergen45% death40% cardioresp arrest CNS damage

Cranshaw J et al. Anaesthesia 2009; 64: 1317-23.Cranshaw J et al. Anaesthesia 2009; 64: 1317-23.

despite allergy or contra-indication

Overdose: entire amp given at once

Blood to wrong pt

drug forgotton

given too fast

drug expired

syringe already used

%

Drug administration errorsDrug administration errors

Abeysekera A et al. Anaesthesia 2005; 60: 220-Abeysekera A et al. Anaesthesia 2005; 60: 220-7.7.


MisCALCULATINGDose Calculation Error

Decimal Point Misplacement

Drugs most commonly Drugs most commonly misprepared misprepared

by health care professionalsby health care professionals

Morphine

dilution error

NM BLOCKER prepared instead of neostigminVECURONIUM dilution error: H20 w/o vec

Abeysekera A et al. Anaesthesia 2005; 60: 220-27.Abeysekera A et al. Anaesthesia 2005; 60: 220-27.


Most common adverse outcomes: Awake paralysis Respiratory depression requiring ICU

15 errors resulted in severe harm or death

Litigation related to Drug Errors in Anaesthesia: Analysis of Claims


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



MisUNDERSTANDINGMisreading,

use of Abbreviations

Letters & Numerals commonly confused

oo 00cc eegg qqmm nnyy zz

EE FFZZ 22OO 00DD 00SS 88

ZZ 77TT II55 8855 3377 11

Lavin LA, Prescribing ErrorsSt Louis University APNursing Conference, 2012

Cursive Letters & Numerals commonly confused

11 77ii eeaa oo

ff 77gg 99BB 88

Confused Drug Names 1Confused Drug Names 1Drug name Confused with

Zyrtec*Zyrtec* Zyprexa*Zyprexa*

Trental*Trental* Tegretol*Tegretol*

dimenhydrinatedimenhydrinate diphenhydraminediphenhydramine

dobutaminedobutamine dopaminedopamine

chlorpromazinechlorpromazine chlorpropamidechlorpropamide

Beano*Beano* B&O* B&O* belladonna&opiumbelladonna&opium

desipraminedesipramine disopyramidedisopyramidewww.ismp.org, Institute for Safe Medication Practices, Institute for Safe Medication Practices

http://www.ismp.org/

Dimenhydrinate and Dimenhydrinate and DiphenhydramineDiphenhydramine

http://medicscribe.com/2010/05/medication-errors-epinephrinehttp://medicscribe.com/2010/05/medication-errors-epinephrine

Dimenhydrinate = Dimenhydrinate = DRAMAMINEDRAMAMINEDiphenhydramine = Diphenhydramine = BENADRYLBENADRYL

Dimenhydrinate is an anti-emeticDimenhydrinate is an anti-emeticDiphenhydramine is an anti-histaminicDiphenhydramine is an anti-histaminic

Both vials same colorBoth vials same colorBoth have long names beginning with DBoth have long names beginning with DBoth often stored beside each other in kitBoth often stored beside each other in kit


sufentanylsufentanyl fentanylfentanyl

tramadoltramadol trazodonetrazodone

ephedrineephedrine epinephrineepinephrine

Ketalar*Ketalar* ketorolacketorolac

hydrocodonehydrocodone oxycodoneoxycodone

hydromorphonehydromorphone morphinemorphine

Norcuron*Norcuron* Narcan*Narcan*www.ismp.org, Inst. f. Safe Medication Practices, Inst. f. Safe Medication Practices * brand name



clonidineclonidine clozapine, clonazepamclozapine, clonazepam

lorazepamlorazepam Lovaza*Lovaza*

Humalog*Humalog* Humulin*Humulin*

Nexium*Nexium* Nexavar*Nexavar*

nifedipinenifedipine Nimodipine, nicardipineNimodipine, nicardipine

iodineiodine Lodine*Lodine*

Lamisil*Lamisil* Lamictal*Lamictal*

www.ismp.org, Institute for Safe Medication Practices* brand name



Dioval*Dioval* Diovan*Diovan*

Dilaudid-5*Dilaudid-5* Dilaudid*Dilaudid*

disopyramidedisopyramide desipraminedesipramine

Evista*Evista* Avinza*Avinza*

Neo-Synephrine Neo-Synephrine (oymetazoline)(oymetazoline)

Neo-Synephrine Neo-Synephrine (phenylephrine)(phenylephrine)

methadonemethadone Metadate*, Mephyton*Metadate*, Mephyton*

www.ismp.org, Institute for Safe Medication Practices, Institute for Safe Medication Practices


Drug Interaction

SEROTONIN = 5-HYDROXY-TRYPTAMINE

DECREASE METABOLISMMAO Inhibitors:

IsocarboxazidSelegiline (Antiparkinson)

PhenelzineTranylcypromine

MoclobemideAntibiotic Linezolid

Methylene blue

L Tryptophan

Modified according to Rastogi R et al,

Anesthesiology 2011; 115: 1293

INCREASE RELEASEAmphetamines

CocaineEcstasyOpioids

FenfluramineSibutramine

Phenantherene



L Tryptophan

INCREASED INCREASED SEROTONIN RECEPTOR SEROTONIN RECEPTOR

SENSITIVITYSENSITIVITYLithiumLithium



L Tryptophan

SEROTONIN RECEPTOR SEROTONIN RECEPTOR AGONISTSAGONISTS

LSDLSDLysergic acid diethylamideLysergic acid diethylamideDHE Di-hydro ergotamineDHE Di-hydro ergotamine

BuspironeBuspironeTriptansTriptans

MirtazapineMirtazapine



L Tryptophan

RE-UPTAKE INHIBITORS

SSRI Select. Serotonin Reuptake Inhibitors

SNRI Serotonin Noradrenalin Re-uptake Inhibitors

5 HT3 AntagonistsAntidepressants

OpioidsHerbs

Mod. according to Rastogi R et al, Anesthesiology 2011; 115: 1293

L Tryptophan

SSRIEscitolopramCitalopramParoxetineFluoxetineSertraline

OPIOIDSFentanylMethadoneMeperidineDextromethorphanTramadol

SNRIDuloxitineVenlafaxineMilnacipran

5 HT3 ANTAGONISTSOndansetronGranisetron

Herbs GinsengSt John’s Wort

ANTIDEPRESSANTSAmitryptiline, Imipramine, Clomipramine, Desipramine, Trazodone, Nefazodone

Serotonin Re-Uptake Inhibitors

SSRI Selective Serotonin Re-uptake Inhibitors SNRI Serotonin Noradrenalin Re-Uptake Inhibitors

Inhibited Inhibited SerotoninSerotoninRe-uptakeRe-uptake

OPIOIDSHAVE A DUAL EFFECT

IncreasedSerotonin

release

Differential Diagnosis 1Condition Pupils Skin Bowel sounds

Serotonin Syndrome

Mydriasis Diaphoresis hyperactive

Anticholinerg “toxidrome”

Mydriasis Erythema hot, dry

decreased or absent

Neurolept malignant

Normal Diaphoresis, pallor

decreased or normal

Malignant hypertherm

Normal Diaphoresis , mottled

decreased

Boyer EW, Shannon M. NEJM 2005; 352/11: 1112-20. Boyer EW, Shannon M. NEJM 2005; 352/11: 1112-20.

Differential Diagnosis 2Differential Diagnosis 2Condition Drugs

takenTime to develop

Vital signs

Serotonin Syndrome

Prosero tonergic

<12h Hypertens., Tachycardia, Tachypnia, >41.1C

AnticholinergAnticholinerg“toxidrome”“toxidrome”

AnticholinAnticholinergicergic

<12h<12h Hypertens., Tachycardia,Hypertens., Tachycardia,Tachypnia, <38.9CTachypnia, <38.9C

Neurolept Neurolept malignantmalignant

Dopamine Dopamine antagonisantagonistt

1-3 days1-3 days Hypertens., Tachcardia, Hypertens., Tachcardia, Tachypnia, >41.1CTachypnia, >41.1C

Malignant Malignant hyperthermhypertherm

Sux, Inhal Sux, Inhal anestheticanesthetic

30min 30min -24h -24h

Hypertens., Tachcardia, Hypertens., Tachcardia, Tachypnia, up to 46CTachypnia, up to 46C

Boyer Shannon M. NEJM 2005; 352/11: 1112-20. Boyer Shannon M. NEJM 2005; 352/11: 1112-20.

Differential Diagnosis 3Differential Diagnosis 3Condition Musc tone Reflexes Mental Status

Serotonin Syndrome

Increased,more lower extremity

Hyper, clonus (unless masked)

Agitation, coma

Anticholinerg Anticholinerg “toxidrome” “toxidrome”

normalnormal normalnormal Agitated Agitated deliriumdelirium

Neurolept Neurolept malignantmalignant

““lead pipe” lead pipe” rigidityrigidity

Brady Brady reflexiareflexia

Stupor, alert Stupor, alert mutism, comamutism, coma

Malignant Malignant hyperthermhypertherm

Rigor mortis-Rigor mortis-like rigiditylike rigidity

HypoHyporeflexiareflexia

AgitationAgitation

Boyer EW, Shannon M. NEJM 2005; 352/11: 1112-20. Boyer EW, Shannon M. NEJM 2005; 352/11: 1112-20.

The Serotonin Syndrome

1) The serotonin syndrome is a predictable consequence of excess serotonergic agonism of CNS & peripheral serotonergic receptors.

2) Excess serotonin may produce a wide spectrum of clinical findings.

3) Clinical manifestations range from barely perceptible to lethal.

Boyer EW, Shannon M. NEJM 2005; 352/11: 1112-20.

Life Life ThreateningThreatening

ToxicityToxicity

Altered Mental StateRestlessness

Clonus(sustained) HyperthermiaHyperthermia

Muscular Muscular HypertonicityHypertonicity

TremorClonus

(inducible)

Mild Symptoms

MILDADVERSEREACTION

AnxietyAkathisiaTremor

TachycardiaSweatingDiarrhea

Mydriasis

FULLBLOWN

SEROTONINSYNDROME

ClonusHyper-reflexiaHyper-thermia

Hypertension

SEVERESEROTONIN

TOXICITYRigidity

>40CSeizureComa

Discontinue offending

drug(s)

Add. monitoring,hydration, cooling

oxygenation

SEVERESEROTONIN

TOXICITYRigidity

>40CSeizureComa

ICUIntubate & Ventilate

Muscle RelaxantsDialysis

5 HT AntagonistsCYPROHEPTADINE poCHLORPROMAZINE ivBenzosAnticonvulsantsßBlocker Propranolol

The Libby Zion Case

18 yr old patient undergoing psychiatric therapy for

stress: phenelzine, Percodan (aspirin-oxycodone

hydrochloride).

Fever and otalgia: Erythromycin, chlorphenamine

History: cocaine, marihuana, imipramine,

flurazepam, diazepam.

After admission: Acetaminophen, haloperidol,

meperidine.

Asch DA, Parker RM. NEJM 1988; 318/12: 771-5.

TAKE HOME

MESSAGES

Anesthesia errors happen to almost every AP

sooner or later.


The frequency of drug errors in anesthesia is probably much higher than

reported (definition of error).

Fasting S, Gisvold SE. Can J Anesth 2000; 47/11: 1060-67.

In 27 of 28 cases, In 27 of 28 cases,

swaps occur swaps occur

between between

SAME SIZE SYRINGESSAME SIZE SYRINGES

Most frequent Syringe Swaps

FENTANYL intended

NEOSTIGMINE intended

MIDAZOLAM intended

SUCCINYLCHOLINE given




Drugs most commonly misused

by health care professionals


4) Hydrocodone

5) Ibuprofen

6) Acetaminophen

7) Aspirin

2)Anticoagulants

3)Antibiotics

1)Insulin

Drugs most commonly Drugs most commonly misprepared misprepared

by health care professionalsby health care professionals

Morphine

dilution error

NM BLOCKER prepared instead of neostigminVECURONIUM dilution error: H20 w/o vec

Abeysekera A et al. Anaesthesia 2005; 60: 220-27.Abeysekera A et al. Anaesthesia 2005; 60: 220-27.

SSRIEscitolopramCitalopramParoxetineFluoxetineSertraline

OPIOIDSFentanylMethadoneMeperidineDextromethorphanTramadol

SNRIDuloxitineVenlafaxineMilnacipran

5 HT3 ANTAGONISTSOndansetronGranisetron

Herbs GinsengSt John’s Wort

ANTIDEPRESSANTSAmitryptiline, Imipramine, Clomipramine, Desipramine, Trazodone, Nefazodone

Serotonin Re-Uptake Inhibitors

SSRI Selective Serotonin Re-uptake Inhibitors SNRI Serotonin Noradrenalin Re-Uptake Inhibitors

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MEDICATION ERRORS and INTERACTIONS – Things to keep in mind