Podcast 101 – Avoiding Resuscitation Medication Errors – Part I

resus-med-errors

Bryan Hayes

Bryan HayesToday I am lucky to have the opportunity to interview Bryan Hayes, the Pharm ER Tox Guy, on the subject of avoiding medication errors in the ED. Bryan is a pharmacist with a fellowship in toxicology. He tweets as PharmERToxGuy and blogs at Academic Life in EM.

Medication Errors during Resuscitations

  • It is extremely easy to make errors during resuscitations. (Resuscitation 2012;83(4):482-7) Also, read the review by EMLitofNote
  • Pharms in the ED may help (Ann Emerg Med 2010;55(6):513-21)
  • Boarding Patients and Temp Nurses may make things worse (Ann Emerg Med 2010;55(6):522-6 and ( J Healthc Qual 2011;33(4):9-18)
  • Excellent post on code medication error prevention

High-Risk Drugs

Bryan mentioned the PINCH acronym

Potassium, Insulin, Narcotics, Chemotherapy Agents, and Heparin

TPA dosing in stroke and PE

High stress and low use make this drug error-prone

The Resus Review wrote up tPA mixing instructions

The Drip Sheet Project

No calculators or mental math should ever be involved with Resus medication administration. Our drip sheet project attempts to prevent this. These sheets are printed out for mixing and then taped to the infusion pumps.

My tPA Drip sheet for acute stroke and PE

Here is Bryan’s TPA Sheet as well:

hayes-tpa-sheet

EPINEPHrine

The root of all evil for drug errors!

Great article from the Nursing Literature (J Emerg Nurs 2013;39:151)

  • Why the ridiculous dilution-dosing notation?
  • Should we have multiple concentrations?
  • Should we be giving IM dosing?

Are Epipens the Solution?

Bryan had an error where a 1 mg dose was given IV for anaphylaxis. Patient developed ECG changes and troponin leak. He removed the 1 mg/mL vials and replaced them with the much more expensive EPIpens. Other solutions: premade pharmacy IM Syringes or just dispense with IM and give IV infusion for all patients.

Kanwar M. Ann Emerg Med 2010;55(4):341-4

Why are premix bags not readily available everywhere? – Bryan outsources for 6.25mg in D5W 250ml (25mcg/ml) and 2mg in D5W 250ml (6mcg/ml)

Insulin Issues

HyperK

What is the proper accompanying dose of D50 when giving insulin IVP for hyperkalemia?

- 10 units of regular insulin in 500 mL of 10 percent dextrose, given over 60 minutes.

- 10 units of regular insulin bolus, followed immediately by 50 mL of 50 percent dextrose (25 g of glucose) is inadequate! This regimen may provide a greater reduction in serum potassium since the potassium-lowering effect is greater at the higher insulin concentrations attained with bolus therapy. However, hypoglycemia occurs in up to 75 percent of patients treated with the bolus regimen, typically about one hour after the infusion. To avoid this complication, infuse 10 percent dextrose at 50 to 75 mL/hour or give 2 amps of D50 (50 grams) and ensure close monitoring of blood glucose levels.

- Regular insulin IV half-life 30-60 min, dextrose doesn’t last more than an hour

More in Part II in a few weeks

 

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Comments

  1. Just a couple of points. My wife and I are both pharmacists at two different hospitals and have enjoyed the podcast for over two years. Regarding TPA, pharmacists at both of our hospitals are responsible for mixing TPA on stroke patients. Also of note supposedly the manufacturer’s of
    TPA have told my wife’s hospital they will stop reimbursing for drug not used due to the high frequency of wasted drug at their hospital ( neither of us have ver hear it straight from the drug company but wanted to relay that possibility out to the audience.) Reference your site all the time and love following Bryan on Twitter.

    • Ryan, Thanks so much for those comments. I’m glad we have pharmacists following the site in case I stick my foot in my mouth with any med mistakes.

  2. I’m glad you commented on mcg/kg/min vs. mcg/min for adrenaline, noradrenaline, dopamine etc. I started my ICU life in New Zealand where we used mg/h for vasopressors and inotropes, without a weight adjustment. I then moved to NSW, Australia where all the hospitals I’ve worked in thus far use mL/h. However some hospitals use a 4mg/100mL concentration and others use a 6mg/100mL concentration. But wait, there’s more. Once you reach about 40mL/h we switch to “double strength” (8mg/100mL) and then “Quad strength” (16mg/100mL). While this increased concentration makes the nurse’s life easier, and I guess gives everyone an indication that the patient isn’t doing well, I think it has potential to cause problems one day.

    Having said that, the whole point of vasopressors and inotropes (and analgesics and sedatives for that matter) is that they’re titratable. The correct dose is “enough,” so to a degree the concentration doesn’t matter. After working in a new place for a couple of weeks, you figure out what the “average” dose is. The issue, as you stated, is when different units in the same hospital or district use different units of measure.

    Thanks for another great podcast. I’m not sure if you’ll talk about it in the next edition, but I think a huge cause of drug errors in ED/ICU/OR/prehospital is almost identical looking vials containing different things! I’ve heard of at least one case in EMS where a paramedic gave 1mg of adrenaline IV to a patient in APO instead of the intended 20mg of frusemide. For a while in NZ suxamethonium and metoclopramide came in identical ampoules. Same colour writing and everything. I guess it would stop you complaining about nausea…

  3. Ben Dowdy says:

    Great podcast. I’m curious on what your thoughts are on how pediatric resuscitation dosages play into this….in all the prehospital services I’ve worked for, meds are packaged according to standard adult doses, I’m assuming in part to help reduce medication errors. However, this leads to problems with the rare (thankfully) pediatric resuscitation…I’ve been involved either directly or indirectly with medication errors involving weight-based pediatric doses during these cases. I’ve been a proponent of ditching preloads for multi-dose vials to force providers to use weight-based math for all patients as a strategy to prevent these errors, based on the assumption that the more often you perform a task in less stressful situations the easier it is to perform. Does anyone’s institution use a similar pre-calculated sheet for pediatric doses or have any experience in dealing with this issue?

  4. Sean Marshall says:

    I wanted to point out a need for the 1:1000 vial of epinephrine. I think it may be different in other countries but racemic epinephrine is no longer available in Canada. For nebulized epinephrine for stridor, we occasionally need to give 5mg of 1:1000 epi.

    • Great point. That would be one which I would not mind ordering from pharmacy, as the 5 vial thing is already dangerous if given IV rather than via neb.

  5. Epinephrine:
    “Why are premix bags not readily available everywhere? – Bryan outsources for 6.25mg in D5W 250ml (25mcg/ml) and 2mg in D5W 250ml (6mcg/ml)”

    For the latter concentration, 2 mg per D5W 250 ml, I get 8 mcg/ml and not the 6 mcg/ml quoted.
    Thanks for clarifying,
    Lyne

  6. Brian Ericson says:

    Great session and I look forward to part II. Just a quick reference, if one goes to activase.com they can request tpa dosing cards for free. The cards have the info in columns and dosing is calculated across the window as you pull the inner card out finding the weight. We stick one in each of our stroke packets.

  7. I think Joe Lex gives a pretty reasonable and believable explanation of drug shortages in AAEM lectures from 2013 – found it on emedhome, little more info than what Bryan says…

    This avoiding errors podcast very timely.

    Regarding Pedi aspect mentioned above – “The Broslow guy” is obviously way deep into this. Special program (for institutions) but also an app that is about 10 bucks for android device. Another – Pedistat – very slick – I am frequently double checking myself with both of these.

    Cheers

  8. Jeremy says:

    Can you please explain how giving insulin vs subcutaneous is different? I know IV has a shorter duration, but why does it not affect the glucose as much as giving subcutaneous? What is the reasoning behind this? Thanks!

    • LeighAnn says:

      I’m asking the same question as Jeremy above.Maybe I just misunderstood how the question was proposed. I interpreted as though mechanism was different. I’ve searched and can’t find this anywhere. I was under impression subc was less accurate due to varying absorption compared to IV. Please enlighten me. Also, thanks for swinging through Columbus. Thoroughly enjoyed your forum! Thanks!

      • Jeremy and Leighann, glucose transporters are maximally filled at a dose of 1 units/kg/hr IV infusion. Anything beyond this is just wasted insulin from the glucose-lowering perspective. An IV push dose brings plasma levels way beyond this point and most of that insulin is wasted and the duration of action is much shorter than a sub-q dose that mirrors the IV infusion.

        For Hyper-K however, you are trying to activate the Na-K-ATPase, which have a much higher requirement of insulin for maximal activation (i.e. maximal lowering of K).

        Leighann–in the critically ill, an IV INFUSION, is considered to be more consistent than sq dosing. Not IV pushes of insulin.

        • LeighAnn says:

          Thanks for the explanation!

        • Trying to find the source for the 1 unit/kg/hr statement and am having a hard time. I’m just now trying to convince my doctors in ER to switch to subcutaneous administration vs. IV. Thanks!

  9. Mitch page says:

    epi is pretty stable in syringes. I’m aware of a outdoor program that replaced epipens with prefilled syringes Here are two good papers on the topic.

    http://www.ncbi.nlm.nih.gov/pubmed/19558009

    http://apjai.digitaljournals.org/index.php/apjai/article/viewFile/105/113

  10. Another excellent episode, I look forward to part II!

    This is a topic that interests me greatly and I’ve been seeking thoughts and opinions on a project I’ve been working on. It’s a “dynamic” PDF that uses JavaScript to automatically calculate drug dosages once a patient weight has been input. This particular prototype is designed for pediatric drug dosages, but there’s logic built in so it doesn’t exceed maximum doses (or minimum doses, in the case of Atropine) if you reach adult weights, and after selecting age range from a drop-down it automatically selects the proper Dextrose concentration as described in our protocols.

    I know there are a few apps that have this functionality, but they don’t seem as customizable when dosing regimens, concentrations, and practices can change from place to place – or easily distributed. I figured it would also be convenient to print out after you input a weight, used as a customized medication dose sheet.

    If anyone has the time, I look forward to any opinions you may have! Please feel free to e-mail me as well: michael.pieretti [at] bostonmedflight.org

    Thanks!

    https://dl.dropboxusercontent.com/u/12652241/pedDrugCalcPrototype.pdf

    • Holy crap; that is totally bad-assian. I love it. If it had a few more drugs like propofol, etc. this would be a go to item for me. Strong work.

      • Michael Pieretti says:

        Thanks for the kind words, I think it’s got potential. I’ll start throwing together an adult prototype for use at Janus General Hospital!

  11. Great write up by Bryan! Just as a precautionary point…insulin can bind to the surfaces of the IV bag and tubing- especially with conventional PVC material. This would not be so much an issue with insulin infusions for DKA patients where higher concentrations (100 units/100mL at our institution for adults) are used to titrate blood glucose. For hyperkalemia, I feel that shooting 10 units regular insulin into a D10 500 mL bag can have significant losses with a smaller unit amount of insulin per volume. By the time the bag is primed and infusing into the patient, we aren’t very sure how many units the patient has received. For that reason, I still prefer the insulin and dextrose 50% syringe combo.

    • Paul, we address this exact topic in part II, when we discuss insulin drips. I too prefer the straight-up insulin push and D50 push.

  12. This is the second pod I listened. Was really useful. Thankyiu and keep it carry on.

  13. Thanks for another great post Scott

    I have a late comment in favour of using IM adrenaline (or epi) in anaphylaxis.

    When these cases come in I let the nurse and resident scramble around trying to get in a hurried IV while I draw up 300-500mcg of 1:1000 adrenaline and give it IM. By the time the IV is in most patients are feeling better and the danger has passed. The can have a bit of fluid and some top up adrenaline I required.

    And in favour of 1:1000, the main thing I can think of is that it might be kinder when giving it to little toddlers IM. I think the nebulised adrenaline issue mentioned above is a stronger reason for keeping it.

    As for calling it 1:1000 rather than 1mg/mL. I am all in favour of doing away with that stuff. Ditto the 1% lignocaine and the misery of trying to do calculations with sodium from 0.9% or 3% to mmol/L.

    In our place (regional Australia) by the way, we use mcg/min for adrenaline and noradrenaline and mcg/kg/min for dobutamine. I have no idea why. Luckily I almost never order dobutamine so I am spared that. The mcg/min is easy if you stick to 6mg/100mL bags as 1mcg/min=1mL/hr.

  14. Steve Freriks says:

    I am a pharmacist that has worked in the ED in Alberta, Canada for 10+ years now. I am catching up on these podcasts and I downloaded this one first, looking forward to the discussion with Brian D. Hayes. I have to say I was VERY disappointed that Brian generalized and blasted research where pharmacists were involved, stating, “anytime you are looking at a study like this where pharmacists are involved you know there is going to be a little bit of bias, because we are always looking for ways to increase our presence to add more positions and justify what we are doing….”, and “…it is hard to justify those salaries today…”. I take exception to those comments. In our Canadian hospitals, clinical (ward-based) pharmacists providing direct patient care are stretched far too thin, and there are too many hospitalized patients that have numerous drug-related problems that we do not have the manpower to tackle. We depend on research such as this, in addition to our own metrics that we cobble together to make cases for additional pharmacist resources. Shame on you Brian for not standing in solidarity with your profession.

    • Bryan Hayes says:

      Steve,

      Thanks very much for your comments. You are absolutely right in the benefits that pharmacists provide. It has been demonstrated in ICUs, general medical wards, EDs, clinics, etc. My words on the podcast may have come out not exactly as I intended and I appreciate you pointing it out.

      These studies are critical to growing the profession of pharmacy. We cost a lot, and need as much justification as possible to ensure expansion in various hospital areas. In fact, I am using these same studies (and a recent one in CJEM) right now as I try to add more ED pharmacists to my team. If you don’t agree that “it is hard to justify those salaries today,” then I’d invite you to further research the healthcare system in the U.S., particularly in light of the new healthcare laws that are further reducing hospital reimbursements in all directions. Every dollar and salary is scrutinized for the hard-dollars that are saved by having that position in place. In other words, is this position somehow increasing revenue or paying for itself? Pharmacy has a difficult time demonstrating hard-dollar savings, even though we track interventions and know that we save the hospital millions of dollars each year. Instead we look at other data, such as code team involvement and medication error reduction, and estimate the cost savings. I’m not saying this is right, I’m just saying it is the environment in which we work in the U.S.

      The point that needs to be understood is that when we set out to perform studies for which we want and expect the result to be a certain way, it is impossible to eliminate the inherent bias in collecting, analyzing, and interpreting the results. Take the tPA studies for ischemic stroke as an example. It doesn’t mean the data isn’t valid or correct, but we need to be cognizant of how it is looked at by those outside the field.

      I advocate for more pharmacy positions at every chance I get, and I use these studies to do so. We are fortunate in that we are adding an EM pharmacy residency position for next year. It has taken me 3+ years to get that added. Again, I appreciate your feedback, even if negative. Pharmacists are crucial to the safety and optimization of patient care. Take a look at my own publications. At least five are directly related to promoting pharmacy research and practice (PMID 17687061, 18445707, 21378295, 22424997, 23602792).

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