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