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ISMP Trigger Alert List By Causal Medication

From the March 10, 2005 issue

Causal Medication
Trigger
Potential ADE
Amikacin Serum amikacin greater than 35 mcg/mL Toxic amikacin level
Antibiotics Positive stool cultures for C. diff C. difficile infection
Antibiotics Anti-diarrheals C. difficile infection
Antibiotics Metronidazole (oral) C. difficile infection
Antibiotics Vancomycin (oral) C. difficile infection
Antibiotics Clotrimazole troches Thrush
Antibiotics Nystatin oral suspension Thrush
Anticholinergic medications, belladonna alkaloids Physostigmine Anticholineric overdose, belladonna alkaloids overdose
Antidepressants, antipsychotics, local anesthetics, etc. Phenytoin Seizures, arrhythmias
Antidepressants, antipsychotics, local anesthetics, etc. Lorazepam Seizures
Antidepressants, antipsychotics, local anesthetics, etc. Phenobarbital Seizures
Antifungals Antifungal use and increasing serum creatinine Renal insufficiency
Anti-hypertensives Atropine Bradycardia
Antipsychotics Benztropine Extrapyramidal reactions
Antipsychotics Dantrolene Hyperthermia, neuroleptic malignant syndrome
Antivirals Antifungal use and increasing serum creatinine Renal insufficiency
Benzodiazepines Flumazenil Oversedation with benzodiazepine
Beta-blockers Beta-blocker use and triamcinolone Rash
Carbamazepine Serum carbamazepine greater than 12 mcg/mL Toxic carbamazepine level
Cyclosporine Serum cyclosporine greater than 500 mcg/L Toxic cyclosporine level
Digoxin Serum digoxin level greater than 2 ng/mL Toxic digoxin level
Digoxin Digoxin immune fab (Digibind) Toxic digoxin level
Digoxin Digoxin use and increasing creatinine Renal insufficiency
Digoxin and amiodarone Digoxin and amiodarone use Medication interaction leading to digoxin toxicity
Dopamine Nitroglycerin Dopamine extravasation
Dopamine Phentolamine Dopamine extravasation
Enoxaparin Enoxaparin use and increasing creatinine Renal insufficiency
Flouroquinolones Flouroquinolone use and increasing creatinine Renal insufficiency
Gentamicin Serum gentamicin greater than 10 mg/L Toxic gentamicin level
Heparin Protamine Heparin overdose
Heparin Danaparoid and lepirudin Heparin-induced thrombocytopenia
Heparin PTT greater than 100 seconds Excessive anticoagulation with heparin
Heparin, ranitidine, NSAIDs, etc. Platelet count less than 50,000 Drug-induced thrombocytopenia
Injectable chemotherapeutic agents Dimethyl Sulfoxide (DMSO) Chemotherapy extravasation
Injectable chemotherapeutic agents Hyaluronidase Chemotherapy extravasation
Insulin, other hypoglycemic agents Dextrose 50% in water Hypoglycemia
Insulin, other hypoglycemic agents Glucagon Hypoglycemia
Insulin, other hypoglycemic agents Serum glucose (less than 50) Hypoglycemia
Lidocaine Serum lidocaine greater than 5 mcg/mL Toxic lidocaine level
Meperidine, other medications Diazepam Seizures
Metformin Metformin use and increasing creatinine Hepatic insufficiency
Miscellaneous Hydroxyzine Hypersensitivity reaction or drug rash
Miscellaneous Abrupt stop of a medication order ADE
Miscellaneous Transfer to a higher level of care Change in clinical condition
Miscellaneous Methylprednisolone Hypersensitivity reaction
Miscellaneous Droperidol Nausea/emesis
Miscellaneous Fosphenytoin Seizures, arrhythmias
Miscellaneous Rising serum creatinine Renal insufficiency
Miscellaneous Calamine lotion Rash
Miscellaneous Blood eosinophils greater than 6% Eosinophilia related to hypersensitivity reaction
Miscellaneous Diprolene 0.05% Rash
Miscellaneous Rash Hypersenstivity reaction
Miscellaneous Anti-emetics Medication toxicity or overdose
Miscellaneous Charcoal (activated) Medication overdose
Miscellaneous WBC count less than 3,000 Leukopenia related to non-chemotherapy medication6
Miscellaneous Antihistamines Hypersensitivity reactions, drug rash
Miscellaneous Diphenhydramine Hypersensitivity reactions, drug rash, extrapyramidal reaction
Miscellaneous Steroids (topical) Hypersensitivity reactions, drug rash
Miscellaneous Steroids (injectable) Hypersensitivity reactions
Miscellaneous Epinephrine Hypersensitivity reactions
Miscellaneous Topical corticosteroids Rash
Miscellaneous 1 Calcium chloride Hypocalcemia
Miscellaneous 1 Calcium gluconate Hypocalcemia
Miscellaneous 2 Hepatotoxic medications and increasing ALT (20%) Hepatic insufficiency
Miscellaneous 2 Serum ALT greater than 150 Units/L Hepatic insufficiency
Miscellaneous 2 Serum bilirubin greater than 10 mg/dL Hepatic insufficiency
Miscellaneous 2 Hepatotoxic medications and increasing AST (20%) Hepatic insufficiency
Miscellaneous 3 Potassium sliding scale and creatinine greater than 2 Renal insufficiency
Miscellaneous 3 Magnesium sliding scale and creatinine greater than 2 Renal insufficiency
Miscellaneous4 Absolute reticulocyte count greater than 2% Hemolytic anemia
NSAIDs Blood transfusions NSAID-induced gastric bleeds
Opiates Naloxone Narcotic overdose
Opiates Combination of 3 or more narcotics ordered Opiate-related side effects
Opium tincture (mistaken for paregoric) Opium tincture deodorized Wrong drug error (confusion with paregoric)
Phenytoin Serum phenytoin levels greater than 20 mcg/mL Toxic phenytoin level
Potassium, misc. Serum potassium greater than 6.5 mmol/L Hyperkalemia due to renal insufficiency or drug effect
Potassium, misc. Sodium polystyrene sulfonate (Kayexalate) Hyperkalemia related to renal impairment or drug effect
Procainamide Serum procainamide greater than 10 mcg/mL Toxic procainamide level
Quinidine Serum quinidine greater than 5 mcg/mL Toxic quinidine level
Ranitidine Ranitidine use and creatinine greater than 2 Renal insufficiency
Sedatives, analgesics, muscle relaxants Patient fall ADE related to use of a sedative, analgesic, or muscle relaxant
Sedatives, analgesics, neuromuscular blockers Intubation or respiratory arrest Respiratory depression or aspiration
Theophylline Serum theophylline greater than 20 mcg/mL Toxic theophylline level
Tobramycin Serum tobramycin greater than 10 mg/L Toxic tobramycin level
Toxic phenytoin level Phenytoin level greater than 18 and albumin less than 3.3 Phenytoin overdose
Valproic acid Serum valproate greater than 120 mcg/mL Toxic valproic acid level
Vancomycin Vancomycin (IV) and increasing creatinine Renal insufficiency
Vancomycin Serum vancomycin greater than 50 mg/L Toxic vancomycin level
Warfarin Phytonadione Warfarin overdose
Warfarin INR greater than 6 Excessive anticoagulation with warfarin

  1. Some medications that can cause hypocalcemia: Foscarnet, phosphate infusion, infusion of citrated blood products, contrast agents containing EDTA
  2. Some medications that can cause hepatic toxicity: Lipid-lowering agents, NSAIDS, antidiabetic agents (pioglitazone, acarbose, sulfonylureas), antibiotics, antifungals
  3. Some medications that can cause renal toxicity: aminoglycosides, angiotensin converting enzyme (ACE) inhibitors, acyclovir, amphotericin B, carboplatin, cisplatin, cyclosporine, foscarnet, ifosfamide, metformin, nonsteroidal anti-inflammatory agents,
  4. Some medications that can cause hemolytic anemia: penicillins, cephalosporins, levodopa, methyldopa, mefenamic acid, quinidine, salicylic acid, sulfonamides, Thiazide diuretics, antazoline, chlorpromazine, isoniazid, streptomycin, ibuprofen

References:
Classen DC, Pestotnik SL, Evans RS, Burke JP. Computerized Surveillance of Adverse Drug Events in Hospital Patients. JAMA; Nov 27, 1991;266(20):2847-51.
Jha AK, Kuperman GJ, Teich JM, et al. Identifying Adverse Drug Events: Development of a Computer-based Monitor and Comparison with Chart Review and Stimulated Voluntary Report. JAMIA; May/Jun 1998;5(3):305-14.
Riedl MA, Casillas AM. Adverse Drug Reactions: Types and Treatment Options. Am Fam Physician;Nov 1, 2003;68(9):1781-90.
Rozich JD, Resar RK. Adverse drug event trigger tool: a practical methodology for measuring medication related harm. Qual Saf Health Care 2003;12:194-200.
Silverman JB, Stapinski CD, Huber C, et al. Computer-based system for preventing adverse drug events. Am J Health-Syst Pharm;Aug 1, 2004;61:1599-603.
Winterstein AG, Hatton RC, Gonzalez-Rothi R, et al. Identifying Clinically Significant Preventable Adverse Drug Events Through a Database of Adverse Drug Reaction Reports. Am J Health-Syst Pharm;2002;59(18):1742-9.

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