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