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Adverse Events in Medication Administration Medication Errors and Risk Reduction.

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Presentation on theme: "Adverse Events in Medication Administration Medication Errors and Risk Reduction."— Presentation transcript:

1 Adverse Events in Medication Administration Medication Errors and Risk Reduction

2 Why this is important… Stevens- Johnson Syndrome Stevens- Johnson Syndrome Toxic Epidermal Necrolysis Toxic Epidermal Necrolysis NSAIDs, PCN, Tegretol, dilantin, sulfonamides NSAIDs, PCN, Tegretol, dilantin, sulfonamides Cough, aches, H/A, fever, sloughing Cough, aches, H/A, fever, sloughing

3 Classification of Med Errors Potential Error Potential Error Error, No Harm Error, No Harm Error, Harm Error, Harm Error, Death Error, Death Reporting is your professional and ethical responsibility

4 Where and what to report? Medwatch – the FDA website http://www.fda.gov/Safety/MedWatch/defa ult.htm Medwatch – the FDA website http://www.fda.gov/Safety/MedWatch/defa ult.htm http://www.fda.gov/Safety/MedWatch/defa ult.htm http://www.fda.gov/Safety/MedWatch/defa ult.htm What to report and not to report… http://www.fda.gov/Safety/MedWatch/How ToReport/ucm085568.htm What to report and not to report… http://www.fda.gov/Safety/MedWatch/How ToReport/ucm085568.htm http://www.fda.gov/Safety/MedWatch/How ToReport/ucm085568.htm http://www.fda.gov/Safety/MedWatch/How ToReport/ucm085568.htm This would be for a new or severe adverse event – not an error in administration… This would be for a new or severe adverse event – not an error in administration…

5 What happened? Patient on levaquin IV. New order for Lasix IV push. Stopped the Levaquin, ran the Saline line at 100 for 25- 30. Then proceeded to push the Lasix. I drew back and the syringe looked a little cloudy, started to push it but then second guessed myself and stopped. Only then did I see the crystallization. What did I do wrong? Patient on levaquin IV. New order for Lasix IV push. Stopped the Levaquin, ran the Saline line at 100 for 25- 30. Then proceeded to push the Lasix. I drew back and the syringe looked a little cloudy, started to push it but then second guessed myself and stopped. Only then did I see the crystallization. What did I do wrong? Did I need to flush it longer or should I have gotten a new saline bag and pushed it through a new line? I keep thinking what if I continued to push the lasix? What would happen? Did I need to flush it longer or should I have gotten a new saline bag and pushed it through a new line? I keep thinking what if I continued to push the lasix? What would happen? I am a new nurse, but it doesn't excuse my mistake. I am a new nurse, but it doesn't excuse my mistake. Reference http://www.umm.edu/altmed/drugs/levofloxacin- 075755.htm Reference http://www.umm.edu/altmed/drugs/levofloxacin- 075755.htm http://www.umm.edu/altmed/drugs/levofloxacin- 075755.htm http://www.umm.edu/altmed/drugs/levofloxacin- 075755.htm

6 What happened? Gentamicin (an aminoglycoside antibiotic) was running IV through a direct line. There was a new order for ticarcillin so the nurse piggybacked it into the line with the gentamicin and gave them at the same time the next day. The patient was not getting better. Gentamicin (an aminoglycoside antibiotic) was running IV through a direct line. There was a new order for ticarcillin so the nurse piggybacked it into the line with the gentamicin and gave them at the same time the next day. The patient was not getting better. Reference http://www.umm.edu/altmed/drugs/ticarcillin-and- 125300.htm Reference http://www.umm.edu/altmed/drugs/ticarcillin-and- 125300.htm http://www.umm.edu/altmed/drugs/ticarcillin-and- 125300.htm http://www.umm.edu/altmed/drugs/ticarcillin-and- 125300.htm

7 What happened? A client with anemia was prescribed iron (ferrous sulfate). It bothered her stomach so she took Tums and ate a large meal before each pill. Her hemaglobin and hematocrit (H&H) remained low. A client with anemia was prescribed iron (ferrous sulfate). It bothered her stomach so she took Tums and ate a large meal before each pill. Her hemaglobin and hematocrit (H&H) remained low. After teaching by the nurse, she stopped the Tums and started taking the ferrous sulfate with orange juice only. She developed lethargy, nausea, heartburn and other GI disturbances. After teaching by the nurse, she stopped the Tums and started taking the ferrous sulfate with orange juice only. She developed lethargy, nausea, heartburn and other GI disturbances.

8 What happened? The client was prescribed Lipitor (atorvastin) for hyperlipidemia. He also followed healthy eating habits, including adding grapefruit juice for three meals a day. Lab work showed lowered lipid levels, but elevated CK and liver function tests (AST, ALT). He developed rhabdomyolysis and liver failure. The client was prescribed Lipitor (atorvastin) for hyperlipidemia. He also followed healthy eating habits, including adding grapefruit juice for three meals a day. Lab work showed lowered lipid levels, but elevated CK and liver function tests (AST, ALT). He developed rhabdomyolysis and liver failure. Reference http://www.nature.com/clpt/journal/v66/n2/abs/cl pt1999434a.html Reference http://www.nature.com/clpt/journal/v66/n2/abs/cl pt1999434a.html http://www.nature.com/clpt/journal/v66/n2/abs/cl pt1999434a.html http://www.nature.com/clpt/journal/v66/n2/abs/cl pt1999434a.html

9 What happened? A nurse checks in on a patient living in a supervised group home who takes Nardil (phenalzine; MAO-A inhibitor). The nurse finds a BP of 210/109 and HR of 125. The client says “I shouldn’t feel this bad because it was my birthday and my family brought my favorite foods, swiss cheese and chocolate cake. Don’t tell, but I even had a small glass of Chianti.” A nurse checks in on a patient living in a supervised group home who takes Nardil (phenalzine; MAO-A inhibitor). The nurse finds a BP of 210/109 and HR of 125. The client says “I shouldn’t feel this bad because it was my birthday and my family brought my favorite foods, swiss cheese and chocolate cake. Don’t tell, but I even had a small glass of Chianti.” Reference http://www.nature.com/clpt/journal/v66/n2/abs/clpt19994 34a.html Reference http://www.nature.com/clpt/journal/v66/n2/abs/clpt19994 34a.html http://www.nature.com/clpt/journal/v66/n2/abs/clpt19994 34a.html http://www.nature.com/clpt/journal/v66/n2/abs/clpt19994 34a.html How about MAO-B inhibitors like Eldepryl? How about MAO-B inhibitors like Eldepryl? Reference http://www.drugs.com/food- interactions/selegiline.html Reference http://www.drugs.com/food- interactions/selegiline.htmlhttp://www.drugs.com/food- interactions/selegiline.htmlhttp://www.drugs.com/food- interactions/selegiline.html

10 What happened? A client takes Coumadin (warfarin) to prevent blood clots due to atrial fibrillation. His INR been stable from 2.2-2.4 for the last 3 months taking 2.5 mg every day. In June, the client was admitted for a TIA and the INR was 1.3. On questioning, the nurse discovered he had just harvested his first crop of spinach. A client takes Coumadin (warfarin) to prevent blood clots due to atrial fibrillation. His INR been stable from 2.2-2.4 for the last 3 months taking 2.5 mg every day. In June, the client was admitted for a TIA and the INR was 1.3. On questioning, the nurse discovered he had just harvested his first crop of spinach. Coumadin – PT / INR - antidote Vitamin K Coumadin – PT / INR - antidote Vitamin K Heparin – PTT – antidote protamine sulfate Heparin – PTT – antidote protamine sulfate

11 What happened? Following CABG, a client was told to take aspirin (NSAID) to decrease inflammation and inhibit platelet aggregation. After the development of mild CHF, Lasix (furosemide; loop diuretic), was prescribed. When cellulitis developed at the incision site, tobramycin (aminoglycoside) was added. Today the client cannot hear and has an increased creatinine level of 2.4 mg/dl. Following CABG, a client was told to take aspirin (NSAID) to decrease inflammation and inhibit platelet aggregation. After the development of mild CHF, Lasix (furosemide; loop diuretic), was prescribed. When cellulitis developed at the incision site, tobramycin (aminoglycoside) was added. Today the client cannot hear and has an increased creatinine level of 2.4 mg/dl.

12 What happened? A client with a history of asthma took Advil (ibuprofen, an NSAID) for a headache. She developed a profusely runny nose, itchy eyes, and urticaria. She began to have difficulty breathing, first with wheezing, then with severely decreased breath sounds. She then went into shock. A client with a history of asthma took Advil (ibuprofen, an NSAID) for a headache. She developed a profusely runny nose, itchy eyes, and urticaria. She began to have difficulty breathing, first with wheezing, then with severely decreased breath sounds. She then went into shock. A rare NSAID allergy!! But it happens… A rare NSAID allergy!! But it happens…

13 What happened? A 17 year old girl went with her mother to seek treatment for her acne and was prescribed tetracycline. She did not tell the provider that she had been prescribed birth control pills by a clinic. A month later, she was pregnant. http://www.patient.co.uk/medicine/Tetracycline- Oral.htm A 17 year old girl went with her mother to seek treatment for her acne and was prescribed tetracycline. She did not tell the provider that she had been prescribed birth control pills by a clinic. A month later, she was pregnant. http://www.patient.co.uk/medicine/Tetracycline- Oral.htm http://www.patient.co.uk/medicine/Tetracycline- Oral.htm http://www.patient.co.uk/medicine/Tetracycline- Oral.htm

14 What happened? Client received ampicillin (beta-lactam antibiotic (penicillin) and developed a rash, hives, itching and swelling of lips and eyes. Switched to cefazolin (cephalosporin). Developed wheezing, rapid weak pulse, N/V/D. Became hypotensive and died. Client received ampicillin (beta-lactam antibiotic (penicillin) and developed a rash, hives, itching and swelling of lips and eyes. Switched to cefazolin (cephalosporin). Developed wheezing, rapid weak pulse, N/V/D. Became hypotensive and died.

15 Questions? For drug interactions, visit http://medicine.iupui.edu/clinpharm/ddis/


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