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Clinical Guideline Omitted or delayed doses: Critical drugs list Document type Document name Document location Version Effective from Review date Owner Author Approved by, date Superseded documents Related documents Keywords Relevant external law, regulation, standards Date DTC reference: 14023b2 Document Details Guideline Omitted or delayed doses: critical drugs list GTi Clinical Guidance Database 3.0 June 2014 June 2017 Pharmacy for Trust Medicines Safety Forum Alice Oborne, Consultant Pharmacist – Safe Medication Practice Drugs and Therapeutics Committee, June 2014 Omitted or delayed doses: critical drugs list v2.0 Medicines Policy: Codes of administration and prescribing; Surviving sepsis guidance; Management of febrile neutropenia; Omit, omitted, omission, delay, refuse, nil by mouth, sepsis, insulin, Parkinson’s disease, epilepsy, critical drug; medication supply, administration, anticoagulant Reducing harm from omitted and delayed medicines in hospital NPSA/2010/RRR009, February 2010 Change History Change details since approval Approved by Review by: June 2017 Critical drugs not to be omitted or delayed 1. Definition of a delayed dose Medication prescription or administration more than two hours after the time the dose is due For antimicrobials in severe sepsis: prescription and administration more than one hour after diagnosis 2. Definition of an omitted dose Failure to prescribe a drug in a timely manner Failure to administer a dose before the next dose is due In the case of once only doses, failure to administer dose within 2 hours of the time it is due 3. Steps to prevent omitted and delayed doses a. Antimicrobials: Prescribe a once-only dose when initiating treatment When initiating antimicrobials, prescribe a once-only dose in addition to the regular prescription Specify the time of prescribing, do not add time to obtain and prepare the dose (definitions allow one-two hours already) The first scheduled dose should be given at the prescribed time, regardless of the time interval since the once-only dose b. Communication with nursing staff Prescribers must inform the attending nurses when they prescribe or adjust the dose or frequency of a drug on the critical drug list. In particular, prescribers must advise the attending nurse when they prescribe once-only doses For doses intentionally to be omitted under instruction of the medical team, record this using code “8”, prescriber’s initials and document a reason. Do not use X as this is imprecise. c. Obtaining supplies of critical drugs not to be omitted or delayed Nursing staff must ensure that drugs in this list are obtained urgently from pharmacy if they are not already present in the clinical area. E.g. if documenting a dose omission, follow Figure 1. Out of hours, stock items for the ward may be borrowed from stock held on other wards. Out of hours on Guy’s site, drugs can be obtained from the Emergency Drug Cupboard on Guys Critical Care Unit. Contact the resident pharmacist to check availability in the Emergency Drug Cupboard (this also facilitates Cupboard refilling). Non-stock items can be requested from pharmacy via the on-call pharmacists. 4. Action in case of omission or delayed dose of critical drug In addition to pursuing a supply of the critical drug as above, staff should a. discuss the omission with the nurse in charge b. Tell the attending medical team, within an appropriate timeframe c. Report the critical omission or delayed drug via incident reporting on GTi. 5. Critical drugs that should not be inappropriately omitted or delayed The Tables below list conditions and examples of drugs which should not be omitted or delayed The lists are not exhaustive. Patient acuity should be considered. There may be occasions when, based on clinical judgement, it is appropriate to delay or omit medication. The rationale for this decision must be clearly documented. DTC reference: 14023b2 Review by: June 2017 Conditions and drugs which should not be inappropriately omitted or delayed Note that this list is not exhaustive. Table 1. Condition Sepsis: Give antimicrobials within 1 hour of diagnosis Sepsis – fluid resuscitation Infection Particularly in first 48 hours of therapy Thrombosis or prevention of thrombosis (blood clot) Epilepsy or prevention of fits Parkinson’s disease Diabetes mellitus and tight glycaemic control Patients on long-term steroids Transplant recipients Ulcerative colitis, vasculitis, systemic lupus erythematosus, other autoimmune conditions HIV infection Severe pain Post-operative pain Acute asthma, acute chronic obstructive pulmonary disease Acute coronary syndromes, Acute ischaemic stroke, or immediately post-PCI Acute severe hypertension Bradycardia e.g. post-MI Acute arrhythmias Low oxygen saturation Fluid overload, severe heart failure Acute upper GI bleed Acute alcohol withdrawal or acute drug withdrawal Resuscitation, anaphylaxis Warfarin or heparin overdose Opiate overdose Examples of drugs Antibiotics, antifungals, antivirals Risk if omitted or delayed Mortality increases hourly IV fluids Systemic antibiotics e.g. co-amoxiclav, ceftriaxone; antivirals e.g. aciclovir; antifungals, antimalarials Warfarin, dalteparin, heparin, dabigatran Phenytoin, levetiracetam, sodium valproate, carbamazepine, diazepam, phenobarbitone Co-beneldopa, co-careldopa, entacapone pramipexole, ropinirole, rotigotine Stalevo Insulins IV glucose 20%, glucagon Hydrocortisone, dexamethasone, prednisolone, fludrocortisone Ciclosporin, tacrolimus, sirolimus, cyclophosphamide, mycophenolate mofetil, Antithymocyte globulin, methylprednisolone IV ciclosporin, cyclophosphamide, mycophenolate mofetil, azathioprine, methylprednisolone Atripla, darunavir, Kaletra, ritonavir, tenofovir, Truvada Strong analgesics e.g. morphine, oxycodone, fentanyl, buprenorphine Salbutamol nebules Ipratropium nebules Aspirin loading dose, clopidogrel, abciximab, alteplase, IV glyceryl trinitrate, IV metoprolol, IV labetolol, IV labetolol, IV glyceryl trinitrate, Atropine Once-only IV doses of digoxin, metoprolol amiodarone, magnesium, adenosine Oxygen IV furosemide IV pantoprazole, terlipressin IV vitamins (Pabrinex) Chordiazepoxide, diazepam, lorazepam Parenteral adrenaline, IV hydrocortisone, IV chlorphenamine Vitamin K (phytomenadione) Beriplex, Octaplex, protamine Naloxone Worsening of infection, microbial resistance Progression of thrombus; embolism Loss of seizure control or failure to treat seizures Poor control e.g. immobility, unable to swallow doses Poor glycaemic control, brain damage, ketoacidosis Risk of Addisonian crisis Transplant rejection Delay or failure to control disease e.g. perforation necessitating colectomy. Emergence of viral resistance Avoidable pain Failure to treat acutely ill patient Poor outcome or death Failure to treat acutely ill patient Harm from hypoxia Failure to treat acutely ill patient GI haemorrhage Permanent brain damage, seizures Failure to treat acutely ill patient Haemorrhage Iatrogenic benzodiazepine overdose (see footnote) Severe hyperkalaemia Flumazenil Respiratory depression, death Respiratory depression IV calcium gluconate, glucose with insulin Fatal arrhythmia Other severely abnormal electrolyte levels Thyrotoxicosis Before scans that use nephrotoxic contrast media Head injury First IV doses of potassium, calcium, magnesium, phosphate IV propranolol, hydrocortisone N-acetylcysteine Failure to treat acutely ill patient DTC reference: 14023b2 Tranexamic acid Nephropathy, anaphylactoid reaction Intracerebral bleed Review by: June 2017 Table 2. Additional critical conditions and drugs not to delay, used in specific areas Note that this list is not exhaustive. Table 2. Condition Risk if omitted or delayed Examples of drugs Drugs more likely to be used in Emergency Department and Acute Admission areas Overdose or poisoning N-acetylcysteine, naloxone, other treatments. See: Liver damage, College of Emergency Medicine and National Poisons severe harm, death Information Service guidance: http://www.collemergencymed.ac.uk/ShopFloor/Clinical%20Guidelines/ Bites or cuts Tetanus immunoglobulin, rabies immunoglobulin Infection, death Blood exposure, bites Hepatitis B Infection, death or needle sticks Post-exposure prophylaxis of HIV Drugs more likely used in Ophthalmic Emergency areas Acute glaucoma, Acetazolamide, cyclopentolate severe infection, intravitreal antimicrobial, potassium ascorbate chemical burn Eye damage, blindness Drugs more likely to be used in Women’s Health areas Unprotected Ulipristal acetate, levonorgestrel for emergency intercourse hormonal contraception Induction and Dinoprostone, misoprostol, oxytocin augmentation of labour Premature labour Nifedipine, atosiban Betamethasone for foetal lungs Rhesus negative Anti-D (Rho) immunoglobulin pregnant women Unwanted pregnancy Failure to progress Premature birth; Lung damage Foetal anaemia in future pregnancies Drugs more likely to be used in Critical Care and Theatres Hypotension Dobutamine, dopamine, noradrenaline, adrenaline, ephedrine Induction of Intravenous, inhalational anaesthetics anaesthetic Failure to treat acutely ill patient No anaesthesia Drugs more likely to be used in Surgical areas and Theatres Critical ischaemia Iloprost, alteplase Before surgery or Bowel preparations: Picolax, senna, Gastrograffin before an endoscopy Premedication, Local anaesthetic before procedure Loss of digit/ limb Delayed or cancelled procedure, pain Drugs more likely to be used in Paediatrics Metabolic syndromes Sodium phenylbutyrate, Sodium benzoate, Carboglu Drugs more likely to be given in Haematology/Oncology or Renal Directorate Specific indications have been listed here; other indications may not be time-critical. Neutropenic sepsis Antimicrobials, filgrastim (GCSF) Increased mortality Acute leukaemias Hydroxycarbamide, all-trans-retinoic-acid, (tretinoin) Treatment failure, deterioration, death Tumours obstructing Etoposide, cisplatin Failure to treat acutely ill superior vena cava patient Malignant spinal cord Dexamethasone Cord compression, compression paralysis Tumour lysis syndrome Rasburicase Electrolyte abnormalities, in leukemia, lymphoma cardiac arrest, convulsion Adjunctive therapies Calcium folinate for high dose methotrexate or Greater toxicity of for chemotherapy overdose, or adjunct to fluouropyrimidine, Mesna, chemotherapy filgrastim; IV fluids to prevent nephrotoxicity Anti-emetics before Ondansetron, aprepitant, dexamethasone Nausea, vomiting chemotherapy Hypercalcaemia of IV fluids Neurotoxicity, malignancy Zolendronic acid, sodium pamidronate arrhythmias, death DTC reference: 14023b2 Review by: June 2017 Figure 1. Steps to be taken to obtain an urgent non-stock drug References and further reading: 1. NPSA Rapid Response Report: Reducing harm from omitted and delayed medicines in hospital NPSA/2010/RRR009.February 2010 2. Gentamicin Alert: NPSA2010/PSA001 3. Medicines Policy: Codes for safe administration and Prescribing 4. TOXBASE www.toxbase.org 5. College of Emergency Medicine and National Poisons Information Service guidance: http://www.collemergencymed.ac.uk/Shop-Floor/Clinical%20Guidelines/ 6. National Poisons Information Service 7. GSTT MAJAX (major incident/accident) drug cupboard list 8. Arrest/resuscitation box contents lists Footnote: flumazenil is only licensed for use in iatrogenic benzodiazepine overdose and should not be used in other situations. Additionally, the use of flumazenil can be associated with convulsions and/or cardiac arrhythmias. DTC reference: 14023b2 Review by: June 2017
