ISMP Trigger Alert List by Causal Medication

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

Some medications that can cause hypocalcemia: Foscarnet, phosphate infusion, infusion of citrated blood products, contrast agents containing EDTA
Some medications that can cause hepatic toxicity: Lipid-lowering agents, NSAIDS, antidiabetic agents (pioglitazone, acarbose, sulfonylureas), antibiotics, antifungals
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,
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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