Solutions for Confusion
Adam Sutherland
Clinical Pharmacist, PICU, RMCH
Clinical Lecturer, University of Manchester
A LIFE IN THE DAY…
Patient A
Monday
6/12
Septic, hypotensive.
Undiagnosed complex
condition
0630
GDD
GORD
Congenital
hyperinsulinaemia
…and the rest!
Hypotensive 35/40
Lactate 5
pH 6.91
0640
Loss of output
CPR commenced
3 x adrenaline
Rx. adrenaline infusion
0.1microgram/kg/min
A LIFE IN THE DAY…
0700
CPR ongoing
Adrenaline infusion commenced
0710
No response to adrenaline.
Dose increased to
2microgram/kg/min
Request to remake infusion
0715
Day nurse and night nurse make
infusion together:
• Day nurse finds adrenaline
ampoules 1:10,000 in tray
TRANSCRIPT
Day (D) “What volume of
1:10,000 did you draw up for that
infusion?”
Night (N) “Just what it said on the
calculator”
D “Just that volume?”
N “Yeah!”
D “They’re different strengths…”
N “No they’re not; they’re the
same. They’re both adrenaline”
D “No! This is ten times weaker
than what’s on the chart…”
A LIFE IN THE DAY…
ROOT CAUSES
1) Human error in wrong concentration
selection
2) Service failure in training
3) 20 minutes to commence infusion
CONTRIBUTING FACTORS
Nursing preparation at the bedside
Rule-of-Six
THE RULE OF SIX
6mg/kg of drug X in 100ml of Diluent Y
Rate = 1ml/hr
Dose = 1microgram/kg/min
2014 infusion pump
1980 vintage infusion pump
THE RULE OF SIX
STRENGTHS
1. Quick calculations at the bedside (?)
2. Embedded into unit practice
3. Predictable fluid load
– But still too much…?
4. Simple to titrate
– As long as you know what the concentration
is in the syringe…
THE RULE OF SIX
1.
2.
3.
4.
WEAKNESSES
Complex prescribing
Complex calculations for dilution and
preparation
Relies on impossibly accurate
measurement and dilution
Slow to deliver from point of ordering
WHY AM I HERE?
To debunk the Rule of Six
To present potential benefits of
standardisation
– Patient care
– Patient safety
– Unit efficiency
DEBUNKING THE RULE OF SIX
• The rule of six CAUSES medication error
–
–
–
–
Prescribing
Calculation
Dilution
Administration
• Errors are common, undetectable and CANNOT be
overcome
–
–
–
–
Parshuram 2003
Wheeler 2007
Allegaert 2011
Aguado-Lorenzo 2013
-
• Not negligent, just human
Opiate infusions in PICU
Inotropes in Adult ICU
Paracetamol in NICU
Opiate infusions in NICU
DEBUNKING THE RULE OF SIX
Ped Crit Care Med 2006; 7(3); 225
DEBUNKING THE RULE OF SIX
Causes of inaccuracy
• Human eye measurements
• Inadequate mixing
• Use of concentrated solutions
Parshuram C et al.
Ped Crit Care Med 2003 31(10);2483
DEBUNKING THE RULE OF SIX
Parshuram et al.
CMAJ 2008; 178(1);42
CMAJ 2008; 178(1): 2
DEBUNKING THE RULE OF SIX
Arch Dis Child 2013:98; 975
DEBUNKING THE RULE OF SIX
DEBUNKING THE RULE OF SIX
What are the implications:
• Patient instability at infusion change
• Slow response to new orders
• Patient response
• Nursing preparation
• Is ongoing instability related to:
• Real instability of the patient OR
• Because the infusion is the wrong strength
DEBUNKING THE RULE OF SIX
Recommendations for IV infusion safety
• Standardisation (Roman 2005)
• Ready mixed ready to use containers (NPSA
2007)
• Longer running infusions (Apkon 2004)
• Electronic prescribing
• Pre-programmed syringe drivers (maybe:
Murdoch 2008 )
Roman, N. (2005). Dimensions of Critical Care Nursing, 24(6), 275–278.
Apkon, M. (2004). Quality and Safety in Health Care, 13(4), 265–271.
Murdoch, L (2008)British Journal of Nursing, 17(10), 630–6.
DEBUNKING THE RULE OF SIX
Fluid load…
Paediatr child Health 2008 13(5):371
DEBUNKING THE RULE OF SIX
REGULATORY ACTION
DEBUNKING THE RULE OF SIX
REGULATORY ACTION
• Risk assessment
• Ready to use solutions
• Reducing ward-level
manipulation
74 incidents in TWO years; 4 “serious harm”; 2
“death”
“Consider pre-filled syringes”
DEBUNKING THE RULE OF SIX
Borthwick et al. 2007; JICS 8(1): 92
DEBUNKING THE RULE OF SIX
IF WE DON’T EFFECT CHANGE
OURSELVES ON OUR TERMS SOMEONE
ELSE WILL FORCE US TO DO IT ON
THEIRS