MEDICATION ERRORS
and INTERACTIONS –
Things to keep in mind
Linda E. Pelinka, MD, PhD,
Medical University of Vienna,
and Boltzmann Institute
for Experimental & Clinical Traumatology
Vienna, Austria,
European Union
TRAUMA
“Errors in judgement
must occur
in the practice of an art
which consists largely in
balancing probabilities.”
Sir William Osler
British Royal College of Physicians 1883
Physician in chief, Johns Hopkins Hospital 1888
Author of Principles & Practice of Medicine
1 drug error per 133 anesthetics
7 drug errors/AP/year
if 1% of errors resulted in injury…
Every AP would harm 2 pts
in a 30 yr career
1000 APs would harm 2000 pts
Glavin RJ. Br J Anaesth 2010; 105/1: 76-82.
Anesthesia professionals in the OR
are the only med personnel who
Prescribe
Secure
Prepare
Administer and
Document medications…
…a process of up to 41 steps.
Martin DE, Penn State College of Medicine. APSF Consensus Conf. 2010
…a process of up to 41 steps.
typically without
standardized protocols and
often in a distracting environment.
These steps usually occur
within a very short time interval,
Martin DE, Penn State College of Medicine. APSF Consensus Conf. 2010
Key System Elements that
influence medication use most





Poor lighting
Cluttered space
Noise
Interruption
Multi-tasking
Grissinger M, Ann Meeting American Pharmacists Ass 2007, Atlanta, GA
Litigation related to
Drug Errors in Anaesthesia:
Analysis of Claims
against the NHS in England
1995-2007
Cranshaw J et al. Anaesthesia 2009; 64: 1317-23.
93 claims
62 drug administration errors
31
wrong drug
25
wrong dose
>50%
neuromuscular
blockers
>30% opioid
overdose incl
neuraxial route
Cranshaw J et al. Anaesthesia 2009; 64: 1317-23.
Syringe swaps,
Labeling,
Routes of
administration
Male, age 58, Syringe Swap
Choosing between only 2 syringes,
both known to contain high-risk drugs,
the provider ASSUMED instead of
reading the syringe label,
before injecting the WRONG DRUG
by the WRONG ROUTE.
Survey of AP
1. Do you ever carry drugs in your pocket?
2. Does every anesthesiologist you know
carry drugs in a pocket?
3. Do you think it’s safe to do so?
100% YES to all 3 questions
Kulli JC, webmm.ahrq.gov
Medication Errors in Anesthetic
Practice: Survey of 687 Practitioners
Orser BA et al.Can J Anaesth 2001; 42/2:139-46.
Most common error: administration of a
muscle relaxant instead of a reversal agent.
Most common contributing factors: Syringe
swaps (70%), label misidentification (47%)
Most anesthesiologists (98%) reported reading
the ampoule label “most of the time”.
Label color was an important secondary cue.
In 27 of 28 cases,
swaps occur
between
SAME SIZE SYRINGES
Fasting S, Gisvold SE. Can J Anesth 2000; 47/11: 1060-67.
Adverse Drug Errors in Anesthesia.
Impact of Coloured Syringe Labels.
Fasting S and Gisvold SE. Can J Anesth 2000; 47/11: 1060-67.
Syringe swaps occurred most often between
syringes of equal size. Neither large letters nor
colour coding were a strong enough visual cue
to prevent errors.
Almost no swaps occurred between syringes
of different sizes. Using one size of syringe
for only one group of drugs might be a strong
enough visual cue to reduce syringe swaps.
Most frequent Syringe Swaps
FENTANYL
intended
SUCCINYLCHOLINE
given
NEOSTIGMINE SUCCINYLCHOLINE
intended
or NM BLOCKER given
MIDAZOLAM
SUCCINYLCHOLINE
intended
or NM BLOCKER given
Abeysekera A et al. Anaesthesia 2005; 60: 220-27.
Litigation related to Drug Errors in
Anaesthesia: Analysis of Claims
against the NHS in England
1995-2007
Cranshaw J et al. Anaesthesia 2009; 64: 1317-23.
Most common adverse outcomes:
 Awake paralysis
 Resp depression requiring ICU
15 errors resulted in severe harm or death
Drug Administration Errors: a
prospective Survey from 3 South
African Teaching Hospitals
Llewellyn RL et al. Anaesth Intensive Care 2009; 37/1: 93-8.
Hospitals A&C treat adults, hospital B peds.
Response rates: A+C 48%, B 81%
Most common errors, A+C: substitution.
B: substitution & incorrect dose.
Causes for amp & syringe swaps (substitution
errors): 21% syringe misidentification,
37% AMPOULE LOOK-ALIKES.
Look-alike Drugs Cause Near Miss
Ge Li, MD, PhD, Elgin IL.
www.apsf.org/newsletters/html/2009/winter/13_lookalikes.htm
To the Editor:
I administered anesthesia to a 4 yr old, 15 kg
girl for tonsillectomy and adenoidectomy.
Because of the size of the tonsils, the surgeon
requested 20 mg of dexamethasone iv.
Glycopyrrolate was in the same drug tray,
close to the dexamethasone vial.
Look-alike Drugs Cause Near Miss
Ge Li, MD, PhD, Elgin IL.
www.apsf.org/newsletters/html/2009/winter/13_lookalikes.htm
I was to give 5 dexamethasone vials (4mg/vial).
5 glycopyrrolate vials (0.4mg/vial) would
have been at least 10 times more than the max
allowable dose.
Luckily, I checked the label.
I think this “look-alike” is something important
and that every anesthesiologist and anesthetist
should be aware of the similarity.
Amp/Vial Swaps
Similar very small writing on amp
Same manufacturer
Same size
Amp/Vial Swaps
Amp/Vial Swaps
Drug Error in Anaesthetic Practice:
Review of 896 Reports from the
Australian Incident Monitoring Study
Database.
Abeysekera A et al. Anaesthesia 2005; 60: 220-27.
Wrong route:
The most significant factor of this section was
the large number of errors associated with
regional anesthesia, despite using the normal
checks, including aspiration to check for blood.
Local Anesthetics: Baricity,
Concentration, Additives
Compatible Cross Connection
The problem of cross-connection
of anesthesia gasses
recognized >50 years ago.
Has been almost eliminated by
mandated use of incompatible
connectors for different gasses.
Preventing catheter/tubing misconnections: Much needed help is
on the way. ISMP Medication Safety Alert! Acute Care Edition.
July 15, 2010; 15: 1-2.
Luer Connector System
Shared by different tubing devices
used in patient care,
including
Periperal catheters
Epidural catheters
IV syringes
Kulli JC, webmm.ahrq.gov
Prescribing
Errors
Most Common
Prescribing Errors 1
Lack of
Lack of
DRUG
PATIENT
knowledge
knowledge
wrong dose
other meds
wrong frequency drug interaction
allergy
Key System Elements
that influence medication use
the most
 Pt info:
age, weight, diagnoses, allergies
 Communication
Grissinger M, Ann Meeting American Pharmacists Ass 2007, Atlanta, GA
Body Weight
Over- & Underestimation,
common cause of medication errors
Unfractionated heparin & LMWH
Glycoprotein IIb/IIIa receptor antagonists
Fibrinolytic agents (alteplase, tenecteplase)
Inotopes (dobutamine)
Vasopressors (dopamine, norepinephrine)
Vasodilators (nesiritide, nitroprusside)
Inodilator milrinone
Cockroft DW and Gault MH. Prediction of Creatinine
Clearance from Serum Creatinine. Nephron 1976; 16: 31-41.
Drugs most commonly
misused
by health care professionals
1)Insulin
2)Anticoagulants
3)Antibiotics
4) Hydrocodone
5) Ibuprofen
6) Acetaminophen
7) Aspirin
Grissinger M, Ann Meeting American Pharmacists Ass 2007, Atlanta, GA
Creatinine Clearance
Correct estimation is one of
the most important factors in dosing
Enoxaparin
Eptifibatide
Tirofiban
Bivalirudin
Dofetilide
Sotalol
Cockroft DW and Gault MH. Prediction of Creatinine
Clearance from Serum Creatinine. Nephron 1976; 16: 31-41.
Top 5 of 355 drugs most
commonly associated with errors
Analgesics
Bronchodilators
Antibacterials
Anti-anginals
Glavin RJ. Br J Anaesth 2010; 105/1: 76-82.
Claims involving
Allergic Reactions
n=31
65%
Previously KNOWN
allergen
>30% Penicillin
35%
20% severe reaction
Previously
UNKNOWN
No lasting sequelae
allergen
45% death
40% cardioresp arrest
CNS damage
Cranshaw J et al. Anaesthesia 2009; 64: 1317-23.
Drug administration errors
despite allergy or
contra-indication
Overdose: entire
amp given at once
Blood to wrong pt
%
drug forgotton
given too fast
drug expired
syringe already used
Abeysekera A et al. Anaesthesia 2005; 60: 220-7.
Most Common
Prescribing Errors 2
MisCALCULATING
Dose Calculation Error
Decimal Point Misplacement
Drugs most commonly
misprepared
by health care professionals
NM BLOCKER
prepared
instead of
neostigmin
VECURONIUM
dilution error:
H20 w/o vec
Morphine
dilution error
Abeysekera A et al. Anaesthesia 2005; 60: 220-27.
Litigation related to Drug Errors in
Anaesthesia: Analysis of Claims
against the NHS in England
1995-2007
Cranshaw J et al. Anaesthesia 2009; 64: 1317-23.
Most common adverse outcomes:
 Awake paralysis
 Respiratory depression requiring ICU
15 errors resulted in severe harm or death
Although
iatrogenic opioid overdosing
is a recurrent error reported
to the NRLS*, it seems
rarely reported in the context
of anesthetic care.
*National Patient Safety Agency National Reporting
& Learning Service
Cranshaw J et al. Anaesthesia 2009; 64: 1317-23.
Most Common
Prescribing Errors 3
MisUNDERSTANDING
Misreading,
use of Abbreviations
Letters & Numerals
commonly confused
o
c
g
m
y
0
e
q
n
z
E
Z
O
D
S
F
2
0
0
8
Z
T
5
5
7
7
I
8
3
1
Lavin LA, Prescribing Errors
St Louis University APNursing Conference, 2012
Cursive Letters & Numerals
commonly confused
1 7
i e
a o
f 7
g 9
B 8
Confused Drug Names 1
Drug name
Zyrtec*
Trental*
dimenhydrinate
dobutamine
chlorpromazine
Beano*
desipramine
Confused with
Zyprexa*
Tegretol*
diphenhydramine
dopamine
chlorpropamide
B&O* belladonna&opium
disopyramide
www.ismp.org, Institute for Safe Medication Practices
Dimenhydrinate and
Diphenhydramine
Dimenhydrinate = DRAMAMINE
Diphenhydramine = BENADRYL
Both vials same color
Both have long names beginning with D
Both often stored beside each other in kit
Dimenhydrinate is an anti-emetic
Diphenhydramine is an anti-histaminic
http://medicscribe.com/2010/05/medication-errors-epinephrine
Confused Drug Names 2
Drug name
sufentanyl
tramadol
ephedrine
Ketalar*
hydrocodone
hydromorphone
Norcuron*
Confused with
fentanyl
trazodone
epinephrine
ketorolac
oxycodone
morphine
Narcan*
www.ismp.org, Inst. f. Safe Medication Practices
* brand name
Confused Drug Names 3
Drug name
clonidine
lorazepam
Humalog*
Nexium*
nifedipine
iodine
Lamisil*
Confused with
clozapine, clonazepam
Lovaza*
Humulin*
Nexavar*
Nimodipine, nicardipine
Lodine*
Lamictal*
* brand name
www.ismp.org, Institute for Safe Medication Practices
Confused Drug Names 4
Drug name
Dioval*
Dilaudid-5*
disopyramide
Evista*
Neo-Synephrine
(oymetazoline)
methadone
Confused with
Diovan*
Dilaudid*
desipramine
Avinza*
Neo-Synephrine
(phenylephrine)
Metadate*, Mephyton*
www.ismp.org, Institute for Safe Medication Practices
Drug
Interaction
SEROTONIN =
5-HYDROXY-TRYPTAMINE
L Tryptophan
DECREASE METABOLISM
MAO Inhibitors:
Isocarboxazid
Selegiline (Antiparkinson)
Phenelzine
Tranylcypromine
Moclobemide
Antibiotic Linezolid
Methylene blue
Modified
according to Rastogi R et al,
Anesthesiology 2011; 115: 1293
L Tryptophan
INCREASE RELEASE
Amphetamines
Cocaine
Ecstasy
Opioids
Fenfluramine
Sibutramine
Phenantherene
Modified
according to Rastogi R et al,
Anesthesiology 2011; 115: 1293
L Tryptophan
INCREASED SEROTONIN
RECEPTOR SENSITIVITY
Lithium
Modified
according to Rastogi R et al,
Anesthesiology 2011; 115: 1293
L Tryptophan
SEROTONIN RECEPTOR
AGONISTS
LSD
Lysergic acid diethylamide
DHE Di-hydro ergotamine
Buspirone
Triptans
Mirtazapine
Modified
according to Rastogi R et al,
Anesthesiology 2011; 115: 1293
L Tryptophan
RE-UPTAKE
INHIBITORS
SSRI Select. Serotonin
Reuptake Inhibitors
SNRI Serotonin Noradrenalin
Re-uptake Inhibitors
5 HT3 Antagonists
Antidepressants
Opioids
Herbs
Mod. according to Rastogi R et al,
Anesthesiology 2011; 115: 1293
Serotonin Re-Uptake Inhibitors
SSRI
Escitolopram
Citalopram
Paroxetine
Fluoxetine
Sertraline
SNRI
Duloxitine
Venlafaxine
Milnacipran
Herbs Ginseng
St John’s Wort
ANTIDEPRESSANTS
Amitryptiline, Imipramine,
Clomipramine, Desipramine,
Trazodone, Nefazodone
OPIOIDS
Fentanyl
Methadone
Meperidine
Dextromethorphan
Tramadol
5 HT3
ANTAGONISTS
Ondansetron
Granisetron
SSRI Selective Serotonin Re-uptake Inhibitors
SNRI Serotonin Noradrenalin Re-Uptake Inhibitors
OPIOIDS
HAVE A DUAL EFFECT
Increased Inhibited
Serotonin Serotonin
release Re-uptake
Differential Diagnosis 1
Condition
Serotonin
Syndrome
Pupils
Skin
Mydriasis Diaphoresis
Bowel sounds
hyperactive
Anticholinerg Mydriasis
“toxidrome”
Erythema hot, decreased or
dry
absent
Neurolept
malignant
Normal
Diaphoresis,
pallor
Malignant
hypertherm
Normal
Diaphoresis , decreased
mottled
decreased or
normal
Boyer EW, Shannon M. NEJM 2005; 352/11: 1112-20.
Differential Diagnosis 2
Time to
Vital signs
develop
Serotonin
<12h
Hypertens.,
Syndrome
Tachycardia,
Tachypnia, >41.1C
Anticholinerg Anticholin <12h
Hypertens., Tachycardia,
“toxidrome” ergic
Tachypnia, <38.9C
Condition
Neurolept
malignant
Malignant
hypertherm
Drugs
taken
Prosero
tonergic
Dopamine 1-3 days
antagonis
t
Sux, Inhal 30min
anesthetic -24h
Hypertens., Tachcardia,
Tachypnia, >41.1C
Hypertens., Tachcardia,
Tachypnia, up to 46C
Boyer Shannon M. NEJM 2005; 352/11: 1112-20.
Differential Diagnosis 3
Condition Musc tone Reflexes
Serotonin
Syndrome
Increased,
more lower
extremity
Anticholinerg normal
“toxidrome”
Mental Status
Hyper,
clonus
(unless
masked)
normal
Agitation, coma
Brady
reflexia
Stupor, alert
mutism, coma
Neurolept
malignant
“lead pipe”
rigidity
Malignant
hypertherm
Rigor mortis- Hypo
like rigidity reflexia
Agitated delirium
Agitation
Boyer EW, Shannon M. NEJM 2005; 352/11: 1112-20.
The Serotonin Syndrome
Boyer EW, Shannon M. NEJM 2005; 352/11: 1112-20.
1) The serotonin syndrome is a predictable
consequence of excess serotonergic
agonism of CNS & peripheral
serotonergic receptors.
2) Excess serotonin may produce
a wide spectrum of clinical findings.
3) Clinical manifestations range from
barely perceptible to lethal.
Altered Mental State
Clonus
Hyperthermia
Restlessness
(sustained)
Life
Threatening
Toxicity
Mild
Symptoms
Tremor
Clonus
(inducible)
Muscular
Hypertonicity
MILD
ADVERSE
REACTION
Anxiety
Akathisia
Tremor
Tachycardia
Sweating
Diarrhea
Mydriasis
Discontinue
offending
drug(s)
FULL
BLOWN
SEROTONIN
SYNDROME
Clonus
Hyperreflexia
Hyperthermia
Hypertension
Add. monitoring,
hydration, cooling
oxygenation
SEVERE
SEROTONIN
TOXICITY
Rigidity
>40C
Seizure
Coma
SEVERE
SEROTONIN
TOXICITY
Rigidity
>40C
Seizure
Coma
5 HT Antagonists
CYPROHEPTADINE po
CHLORPROMAZINE iv
Benzos
Anticonvulsants
ßBlocker Propranolol
ICU
Intubate & Ventilate
Muscle Relaxants
Dialysis
The Libby Zion Case
Asch DA, Parker RM. NEJM 1988; 318/12: 771-5.
18 yr old patient undergoing psychiatric therapy for
stress: phenelzine, Percodan (aspirin-oxycodone
hydrochloride).
Fever and otalgia: Erythromycin, chlorphenamine
History: cocaine, marihuana, imipramine,
flurazepam, diazepam.
After admission: Acetaminophen, haloperidol,
meperidine.
TAKE HOME
MESSAGES
Anesthesia errors
happen to almost every AP
sooner or later.
The frequency of drug errors
in anesthesia is probably much
higher than reported
(definition of error).
Kulli JC, webmm.ahrq.gov
In 27 of 28 cases,
swaps occur
between
SAME SIZE SYRINGES
Fasting S, Gisvold SE. Can J Anesth 2000; 47/11: 1060-67.
Most frequent Syringe Swaps
FENTANYL
intended
SUCCINYLCHOLINE
given
NEOSTIGMINE SUCCINYLCHOLINE
intended
or NM BLOCKER given
MIDAZOLAM
SUCCINYLCHOLINE
intended
or NM BLOCKER given
Abeysekera A et al. Anaesthesia 2005; 60: 220-27.
Drugs most commonly
misused
by health care professionals
1)Insulin
2)Anticoagulants
3)Antibiotics
4) Hydrocodone
5) Ibuprofen
6) Acetaminophen
7) Aspirin
Grissinger M, Ann Meeting American Pharmacists Ass 2007, Atlanta, GA
Drugs most commonly
misprepared
by health care professionals
NM BLOCKER
prepared
instead of
neostigmin
VECURONIUM
dilution error:
H20 w/o vec
Morphine
dilution error
Abeysekera A et al. Anaesthesia 2005; 60: 220-27.
Serotonin Re-Uptake Inhibitors
SSRI
Escitolopram
Citalopram
Paroxetine
Fluoxetine
Sertraline
SNRI
Duloxitine
Venlafaxine
Milnacipran
Herbs Ginseng
St John’s Wort
ANTIDEPRESSANTS
Amitryptiline, Imipramine,
Clomipramine, Desipramine,
Trazodone, Nefazodone
OPIOIDS
Fentanyl
Methadone
Meperidine
Dextromethorphan
Tramadol
5 HT3
ANTAGONISTS
Ondansetron
Granisetron
SSRI Selective Serotonin Re-uptake Inhibitors
SNRI Serotonin Noradrenalin Re-Uptake Inhibitors