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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: Errors @ UWMC ED • Start (or stop) medication – Right Patient – Right Route – Right Drug – Right Dose – Right Time – Right Documentation – Right to Refuse – Right Response 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 Pyxis Oxycodone (immediate) 1-2 hours YES Oxycodone CR or OxyContin 4-5 hours NO Morphine IR Morphine ER or MSContin 1 hour 4 hours NO 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 Drips ICU 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 Drips ICU 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 Drips ICU 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 Drips ICU 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 Drips ICU 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 Policies On UWMC Intranet, “Policies and Procedures” Prostacyclin Policies Under 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 Antibiotics that should be Given FIRST Meropenem, Aztreonam , Ceftriaxone , Cefepime, Ceftazidime, Penicillin G , Piperacillin/Tazobactam IF multiple antibiotics ordered, check compatibility OR give afterwards: Ciprofloxacin, Levofloxacin, Moxifloxacin, Vancomycin Tobramycin, Gentamicin, Metronidazole, Bactrim, ampicillin Sepsis + Antibiotics Questions