Medication Error- A Case Report of Misadventure with Methotrexate.

Methotrexate is an antimetabolite drug with antineoplastic and immunomodulatory properties, useful as an antineoplastic agent in various haematological and solid tumours. MTX toxicity can occur because of accidental ingestion/overdose by the patient or because of prescription error. The toxic effects manifest as severe mucositis or as organ damage (bone marrow depression, renal/hepatic injury). The toxicity usually results from parenteral overdose or repeated chronic drug ingestion. Acute high dose ingestion does not result in MTX toxicity because of saturable absorption kinetics. We present a case of MTX toxicity occurring as a result of prescription error resulting in repeat daily dosing of the drug, and the challenges associated with the management of the same, in a patient with multiple comorbidities. The present case emphasizes on a note of caution on the part of the prescriber and the suggestions regarding the measures which can be taken to avoid MTX toxicity. Keywords: drug overdose; Methotrexate; mucositis; pancytopenia.

Rendimiento y optimización de la herramienta trigger en la detección de eventos adversos en pacientes adultos hospitalizados / Performance and optimisation of a trigger tool for the detection of adverse events in hospitalised adult patients

Objetivo: Caracterizar el rendimiento de los triggers utilizados en la detección de eventos adversos (EA) de pacientes adultos hospitalizados y definir un panel de triggers simplificado suficientemente sensible y específico, para la detección de EA. Método: Estudio transversal de altas de pacientes de un servicio de medicina interna para la detección de EA mediante revisión sistemática de la historia clínica y la identificación de 41 triggers (evento clínico relacionado frecuentemente con EA), determinando si hubo EA según el contexto en que apareció el trigger. Una vez identificado el EA, se procedió a la caracterización de los triggers que lo detectaron. Se aplicó regresión logística para la selección de los triggers con mayor capacidad de detección de EA. Resultados: Se revisaron 291 historias clínicas y se detectaron 562 triggers en 103 pacientes, de los cuales 163 estuvieron implicados en la detección de un EA. Los triggers que detectaron más EA fueron «A.1. Úlcera por presión» (9,82%), «B.5. Laxante o enema» (8,59%), «A.8. Agitación» (8,59%), «A.9. Sobresedación» (7,98%), «A.7. Hemorragia» (6,75%) y «B.4. Antipsicótico» (6,75%). Se obtuvo un modelo simplificado de triggers que incluyó la variable «Número de fármacos» y los triggers «Sobresedación», «Sondaje», «Reingreso en 30 días», «Laxante o enema» y «Cese brusco de la medicación». Este modelo obtuvo una probabilidad del 81% de clasificar correctamente las historias con EA y sin EA (p <0,001; intervalo de confianza del 95%: 0,763-0,871). Conclusiones: Un número elevado de triggers estuvieron asociados a EA. El modelo resumido permite detectar una gran cantidad de EA con un mínimo de elementos (AU)

Objective: To characterise the performance of the triggers used in the detection of adverse events (AE) of hospitalised adult patients and to define a simplified panel of triggers to facilitate the detection of AE. Method: Cross-sectional study of charts of patients from a service of internal medicine to detect EA through systematic review of the charts and identification of triggers (clinical event often related to AE), determining if there was AE as the context in which it appeared the trigger. Once the EA was detected, we proceeded to the characterization of the triggers that detected it. Logistic regression was applied to select the triggers with greater AE detection capability. Results: A total of 291 charts were reviewed, with a total of 562 triggers in 103 patients, of which 163 were involved in detecting an AE. The triggers that detected the most AE were 'A.1. Pressure ulcer' (9.82%), 'B.5. Laxative or enema' (8.59%), 'A.8. Agitation' (8.59%), 'A.9. Over-sedation' (7.98%), 'A.7. Haemorrhage' (6.75%) and 'B.4. Antipsychotic' (6.75%). A simplified model was obtained using logistic regression, and included the variable 'Number of drugs' and the triggers 'Over-sedation', 'Urinary catheterisation', 'Readmission in 30 days', 'Laxative or enema' and 'Abrupt medication stop'. This model showed a probability of 81% to correctly classify charts with EA or without EA (p <0.001; 95% confidence interval: 0.763-0.871). Conclusions: A high number of triggers were associated with AE. The summary model is capable of detecting a large amount of AE, with a minimum of elements (AU)

Adverse outcomes in maternity care for women with a low risk profile in The Netherlands: a case series analysis.

BACKGROUND: This study aimed to perform a structural analysis of determinants of risk of critical incidents in care for women with a low risk profile at the start of pregnancy with a view on improving patient safety. METHODS: We included 71 critical incidents in primary midwifery care and subsequent hospital care in case of referral after 36 weeks of pregnancy that were related to substandard care and for that reason were reported to the Health Care Inspectorate in The Netherlands in 36 months (n = 357). We performed a case-by-case analysis, using a previously validated instrument which covered five broad domains: healthcare organization, communication between healthcare providers, patient risk factors, clinical management, and clinical outcomes. RESULTS: Determinants that were associated with risk concerned healthcare organization (n = 20 incidents), communication about treatment procedures (n = 39), referral processes (n = 19), risk assessment by telephone triage (n = 10), and clinical management in an out of hours setting (n = 19). The 71 critical incidents included three cases of maternal death, eight cases of severe maternal morbidity, 42 perinatal deaths and 12 critical incidents with severe morbidity for the child. Suboptimal prenatal risk assessment, a delay in availability of health care providers in urgent situations, miscommunication about treatment between care providers, and miscommunication with patients in situations with a language barrier were associated with safety risks. CONCLUSIONS: Systematic analysis of critical incidents improves insight in determinants of safety risk. The wide variety of determinants of risk of critical incidents implies that there is no single intervention to improve patient safety in the care for pregnant women with initially a low risk profile.

Patient safety in midwifery-led care in the Netherlands.

OBJECTIVE: to describe the incidence and characteristics of patient safety incidents in midwifery-led care for low-risk pregnant women. DESIGN: multi-method study. SETTING: 20 midwifery practices in the Netherlands; 1,000 patient records. POPULATION: low-risk pregnant women. METHODS: prospective incident reporting by midwives during 2 weeks; questionnaire on safety culture and retrospective content analysis of 1,000 patient records in 2009. MAIN OUTCOME MEASURES: incidence, type, impact and causes of safety incidents. RESULTS: in the 1,000 patient records involving 14,888 contacts, 86 safety incidents were found with 25 of these having a noticeable effect on the patient. Low-risk pregnant women in midwifery care had a probability of 8.6% for a safety incident (95% CI 4.8-14.4). In 9 safety incidents, temporary monitoring of the mother and/or child was necessary. In another 6 safety incidents, reviewers reported psychological distress for the patient. Hospital admission followed from 1 incident. No safety incidents were associated with mortality or permanent harm. The majority of incidents found in the patient records concerned treatment and organisational factors. CONCLUSIONS: a low prevalence of patient safety incidents was found in midwifery care for low-risk pregnant women. This first systematic study of patient safety in midwifery adds to the base of evidence regarding the safety of midwifery-led care for low-risk women. Nevertheless, some areas for improvement were found. Improvement of patient safety should address the better adherence to practice guidelines for patient risk assessment, better implementation of interventions for known lifestyle risk factors and better availability of midwives during birthing care.

The state of risk prevention in a sample of Australian hospitals, medical centres and allied health services.

This paper reports on an investigation into five risk prevention factors (technology, people, organisational structure, culture and top management psychology) to inform organisational preparedness planning and to update managers on the state of health care services. Data were collected by means of a 10-question, cross-sectional survey of key decision-making executives in eight different types of 75 health care organisations. Many organisations were found to have deficient risk prevention practices and allied health organisations were considerably worse than health organisations. Forty per cent of hospitals and chiropractic practices had out-dated or poor technology. Results on organisational culture and structure found that many executives associate these factors with risk prevention, but none of them appreciate the relationship between these factors and crisis causation. Gaps and areas for improvement are identified and a change in top management attitude is recommended to address resource allocation and implement appropriate risk prevention systems and mechanisms. Reactive managers need to increase their awareness of risks in order to become capable of preventing them. Proactive managers are those who invest in risk prevention.

Repeated lung lavage with extracorporeal membrane oxygenation treating severe acute respiratory distress syndrome due to nasogastric tube malposition for enternal nutrition: a case report.

Enternal nutritional support, a frequently applied technique for providing nutrition and energy, played a pivotal role in the treatment of high risk patients. However, severe complications induced by malposition of nasogastric tube caused great danger and even death to the patients. In this case report, we present a patient with severe acute respiratory distress syndrome (ARDS) induced by bronchopleural fistula (BPF) due to malposition of nasogastric tube. Repeated lung lavage combined with extracorporeal membrane oxygenation (ECMO) was performed after transferring to the ICU of our hospital. Finally, the patient recovered and discharged 7 days after admission.

Life-threatening complications following multidose methotrexate for medical management of ectopic pregnancy.

A 25-year-old primigravida was diagnosed to be suffering from unruptured ectopic pregnancy. The serum ß-human chorionic gonadotropin levels were 2851 mIU/l and the ectopic gestational sac was 2.7×2.7 cm without any fetal pole. It was decided to manage her by expectant therapy. But she received medical therapy with multidose methotrexate because of misinterpretation of expectant therapy as medical therapy. She suffered from methotrexate toxicity, which manifested as high-grade fever, vomiting, melena, oral ulcerations, pneumonitis, subconjunctival haemorrhages and skin pigmentation. She developed severe third space fluid collection and shock, which was mistaken for rupture ectopic gestation. Her haematological picture showed severe neutropaenia and thrombocytopaenia which confirmed the clinical picture to be due to methotrexate toxicity. She also developed septicaemia and candidal infection secondary to immunosuppression. She was managed in intensive care unit with ventilatory support, high-dose leucovorin and injection filgastrim. She responded well to the therapy with dramatic recovery in 4 days.

Hyperbaric oxygen treatment to eliminate a large venous air embolism: a case study.

Gas embolism, the entry of gas into vascular structures, can result in serious morbidity and death. It is an inadvertent clinical problem, but it also occurs in non-clinical environments. Gas embolisms result from procedures performed in almost all clinical specialties, thus making it a problem about which all clinicians should be aware. In most cases, gas embolism is air embolism, although it can result from the introduction of gases such as carbon dioxide, nitrous oxide and nitrogen. Gas embolism takes two forms, venous and arterial, distinguished by the mechanism of gas entry and the site where the emboli ultimately lodge. Techniques used to eliminate embolisms including administration of 100% oxygen, placing the patient in lateral decubitus, and Trendelenburg position for no longer than 10 minutes, removing the embolism with a catheter, surfactants and hyperbaric oxygen therapy (HBO2T). For venous gas embolisms surgical removal is recommended, while for arterial embolisms, HBO2T is highly recommended. Here we report on a patient who inadvertently received a venous infusion of 150 ml air resulting in a major embolism, and who underwent HBO2T, recovered well, and suffered no adverse events. This result suggests that it is important to consider HBO2T as a recommended application for patients with venous embolisms.

[Accidents in acupuncture treatment: history and current state].

Acupuncture is widely used as an alternative therapy with few side effects because of its simple manipulation and low cost. However, accidents may occur if the practitioner uses it improperly. Early in the Qin dynasty, the Canon of Medicine mentioned that improper use of acupuncture could cause injury to the body and even death, and it systematically described the occurrence and prevention of acupuncture accidents. Physicians in the successive dynasties frequently reported it, and realized that the manipulation skills were significantly important in preventing the occurrence of acupuncture accidents. Since the 1950s, acupuncture accidents had been effectively prevented because of the improving of acupuncture instruments, enhancing of the quality of the practitioners, popularizing of sterilization and disseminating of anatomic knowledge. Nevertheless, with the renovating of acupuncture techniques, new accidents may occur constantly. The prevention of acupuncture accidents still should be an arduous task for acupuncturists. Nowadays, acupuncture therapy is being used in more than 140 countries, and acupuncture accidents due to improper application are increasing. Prevention of acupuncture accidents has become a global issue deserving of great attention.

Inadvertent subdural spread complicating cervical epidural steroid injection with local anaesthetic agent.

Although cervical epidural steroid injection with local anaesthetic is considered a safe technique and widely practiced, complications may occur. We report a patient experiencing unexpected delayed high block, moderate hypotension and unconsciousness eight to ten minutes after an apparently normal cervical epidural steroid injection. The most probable diagnosis was a subdural block. Anatomical peculiarities of the epidural and subdural space in the cervical region increase the risk of subdural spread during cervical epidural injection. Fluoroscopic guidance is important during cervical epidural injection to increase certainty of correct needle placement, thus minimizing the risk of complications.

Biportal neuroendoscopic microsurgical approaches to the subarachnoid cisterns. A cadaver study.

A preclinical cadaver study was performed to develop the technique of biportal neuroendoscopic dissection in the subarachnoid space of the basal cisterns and to test the feasibility, utility, and safety of this new technique. In 23 fresh post-mortem adult human cadavers and 2 formalin-fixed adult human head specimen a total of 33 biportal endomicrosurgical dissections into and within the basal cisterns were carried out. Following suction of cerebrospinal fluid from the subarachnoid space 0 degree-, 30 degrees-, and 70 degrees-lens-scopes (Aesculap AG, Tuttlingen, Germany) with outer diameters of 4.2 mm and trochars with outer diameters of 5 to 6.5 mm were introduced into the surgical field. 6 different endoscopic routes to the basal cisterns and a total of 10 different combinations of these approaches for biportal endoneurosurgery could be described, but it was found that not all of them were useful and safe. The transventricular approach to the prepontine cisterns through the foramen of Monro and the floor of the third ventricle, biportally combined with a subfrontal or a subtemporal approach, turned out to be not safe enough as it was accompanied by traumatization of the fornix at the interventricular foramen and of the hypothalamus at the level of the tuber cinereum due to relaxation and caudal shift of the brain following suction of cerebrospinal fluid to clear the basal cisterns for the subfrontal or subtemporal approaches. Useful and safe endomicrosurgical approaches to the basal cisterns were: 1st subfrontal, either epidural or intradural, 2nd subtemporal, either anterior or posterior, and 3rd frontal interhemispheric. Various biportal combinations of these approaches are estimated to be feasible, useful, and safe enough to be performed during microsurgical procedures in the operating room. The biportal endomicrosurgical strategy allows for effective and safe dissections within the subarachnoid spaces of the basal cisterns. The tip of the microinstruments as well as the neighboring anatomical structures can be nicely controlled at angles of about 60 degrees to 180 degrees depending on the viewing angles of the scopes used and depending on the individual shape of the head. A variety of microsurgical instruments has been tested. A number of these will have to be redesigned for this new technique. Regions suitable for biportal neuroendoscopic subarachnoid preparations are the olfactory groove, the prechiasmatic cistern, the region of the optic chiasm, the entire suprasellar area, parts of the parasellar area, the pre- and perimesencephalic cisterns, and the prepontine cistern.