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Admitting "overflow" patients to units without proper expertise is a setup for errors

From the October 4, 2000 issue

PROBLEM:Admitting "overflow" patients to a unit where staff expertise may not exist for typically prescribed drug therapy is problematic. Add an excessive workload in the pharmacy, unfamiliarity with glycoprotein IIb/IIIa receptor antagonists, poor handwriting, and failure to dispense drugs in the most ready-to-use form and you have a blueprint for the following error. A patient presented to the ED with sudden onset chest pain. An EKG was performed and acute myocardial infarction (AMI) was suspected. The patient was treated initially with aspirin, LOVENOX (enoxaparin) and RETAVASE (reteplase). Since the CCU was full, the patient was admitted to the surgical ICU where INTEGRILIN (eptifibatide), a glycoprotein IIb/IIIa receptor antagonist used to inhibit platelet aggregation, was started. In acute coronary syndrome, the recommended loading dose is 180 mcg/kg followed by a continuous infusion of 2 mcg/kg/min for up to 72 hours until discharge or coronary artery bypass graft. Unfortunately, the cardiologist's order called for a loading dose of 180 mcg, not 180 mcg/kg. The pharmacy was particularly busy and the pharmacist, who was unfamiliar with Integrilin dosing, did not read the package insert or verify the dose with the prescriber. Additionally, instead of sending the drug in a concentration appropriate for a bolus loading dose (20 mg/10 mL vial), the pharmacist sent the unit a 75 mg/100 mL vial, which is more appropriate for the continuous infusion. The surgical ICU nurse, who had never administered Integrilin, misread the physician's handwritten order as "180 mg." She initiated the loading dose by giving 75 mg over 60 minutes, planning to call the pharmacy for the remainder of the dose later. (A typical 70 kg patient should receive a 12.6 mg loading dose.) Just as the initial infusion was ending, another pharmacist discovered the error and the infusion was discontinued. Fortunately, while platelet inhibition persists during the infusion, its effect dissipates with cessation of the drug. The patient suffered no permanent harm.

SAFE PRACTICE RECOMMENDATION: The hospital involved in this error is now developing an educational program for glycoprotein IIb/IIIa inhibitors. While it's certainly crucial for practitioners to understand indications, contraindications, dosages, and administration procedures for this class of drugs, there's likely to come a time when someone involved in the use of these drugs will have limited knowledge about them. Thus, it's important for pharmacists to play a lead role as a source of drug information. First, pharmacists must ensure that they, themselves, have proper knowledge about the drug before dispensing it. If a patient is admitted to a unit different than expected (e.g., pediatric patient in an adult unit; oncology patient in a general medical unit; AMI patient admitted to a surgical ICU), the pharmacist should communicate important information to the nurse who must administer an unfamiliar drug, especially for "high-alert" drugs such as glycoprotein IIb/IIIa inhibitors. Written protocols, which should be developed before the drug is first used, can also be sent to the unit for easy reference. Clinical pathways or care maps, and standard orders for treating AMI patients can help clearly communicate orders and drug administration procedures. A pharmacist should verify ambiguous orders. Computerized prescriber order entry can also help avoid order misinterpretation and provide alerts when prescribed therapy may be unsafe. The pharmacist should dispense glycoprotein IIb/IIIa inhibitors in a ready-to-use form, and an independent double check should occur before dispensing and administering these drugs. Although difficult, it's equally important to provide pharmacists and nurses with adequate time and a manageable workload to accomplish these important tasks, especially when working with "high alert" drugs.

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