Adverse Events in
Medication Administration
Medication Errors and
Risk Reduction
Why this is important…
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StevensJohnson
Syndrome
Toxic Epidermal
Necrolysis
NSAIDs, PCN,
Tegretol,
dilantin,
sulfonamides
Cough, aches,
H/A, fever,
sloughing
Classification of Med Errors
Potential Error
 Error, No Harm
 Error, Harm
 Error, Death
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Reporting is your professional and ethical
responsibility
Where and what to report?
Medwatch – the FDA website
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
 This would be for a new or severe adverse
event – not an error in administration…
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What happened?
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Patient on levaquin IV. New order for Lasix IV push.
Stopped the Levaquin, ran the Saline line at 100 for 2530. 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?
I am a new nurse, but it doesn't excuse my mistake.
Reference
http://www.umm.edu/altmed/drugs/levofloxacin075755.htm
What happened?
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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-and125300.htm
What happened?
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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.
What happened?
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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
What happened?
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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
How about MAO-B inhibitors like Eldepryl?
Reference http://www.drugs.com/foodinteractions/selegiline.html
What happened?
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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
Heparin – PTT – antidote protamine sulfate
What happened?
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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.
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 rare NSAID allergy!! But it happens…
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What happened?
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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/TetracyclineOral.htm
What happened?
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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.
Questions?
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For drug interactions, visit
http://medicine.iupui.edu/clinpharm/ddis/