Pearls (and perils) of drug administration in the Emergency Department

Joshua Villarreal & 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. Ann Emerg Med.

2010;55:522-526.

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.

The Eight Rights:

• Start (or stop) medication– Right Patient– Right Route – Right Drug – Right Dose– Right Time – Right Documentation – Right to Refuse– Right Response

Errors @ UWMC ED

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 solution

Epinephrine

• New Policy Approved at UWMC• For Acute Allergic Reaction:– Route should always be IM– Dose should always be 0.3mg– Concentration should always be 1mg/mL

Right Drug: Immediate vs. Timed Release

• Immediate release: – Drug absorption NOT delayed beyond original

pharmacokinetic profile– Immediate release (IR)

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)

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)

Right Drug: Immediate vs. Timed Release

Drug Peak PyxisOxycodone (immediate) 1-2 hours YESOxycodone CR or OxyContin 4-5 hours NO

Morphine IR 1 hour NOMorphine ER or MSContin 4 hours YES

Right Drug: Sound Alike Medications

• Metoclopramide vs. Metoprolol

• Benadryl vs. Benazapril

• Clonazepam vs. Clonidine

• Methadone vs. Mephyton

• Dobutamine vs. Dopamine

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/min

Right dose: Sedation & Vasoactive Drips

• Why so confusing?– Units not universally standard• New providers• Drug information resources

– mcg/kg/min vs. mcg/min

Right dose: Sedation & Vasoactive DripsICU 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 dosing

Right dose: Sedation & Vasoactive DripsICU 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 dosing

Right dose: Sedation & Vasoactive DripsICU 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 dosing

Right dose: Sedation & Vasoactive DripsICU 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 dosing

Right dose: Sedation & Vasoactive DripsICU 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 dosing

Right Dose: Heparin

• Multiple Concentrations:– 1 unit/mL– 10 unit/mL– 1,000 units/mL– 5,000 units/mL– Various infusions– Various rates– Various Targets

Right Time: Prostacyclin Infusions

• Life-sustaining continuous infusions:– Treprostinil (Remodulin)– Epoprostenol (Flolan)

http://www.muschealth.com/ph/education/medications.htm

Prostacyclin Policies

• For Patients who present with prostacyclin infusions:– !!!DO NOT INTERRUPT PROSTACYCLIN INFUSION!!!

– !!!DO NOT INTERRUPT PROSTACYCLIN INFUSION!!!

– !!!DO NOT INTERRUPT PROSTACYCLIN INFUSION!!!

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 Policy

Prostacyclin Policies

• Resources for infusion management or infusion complications:– Stephanie Harrie Nolley, Pulmonary Vascular

Nurse Coordinator– STAT nurses– Pharmacists

Prostacyclin PoliciesOn UWMC Intranet, “Policies and Procedures”

Prostacyclin PoliciesUnder Patient Care Services, “Nursing Policies and Procedures”

Prostacyclin Policies

Questions

Sepsis + Antibiotics

• Sepsis: every minute counts…

• Start antibiotics immediately, but which one? And more than one?

Sepsis + Antibiotics

Sepsis + Antibiotics

Questions