New technology, new errors: how to prime an upgrade of an insulin infusion pump.

BACKGROUND: A series of use errors occurred when switching an ambulatory care clinic patient from an older model to a newer model of an ambulatory continuous subcutaneous insulin infusion pump. CASE REPORT: The nurse practitioner (N.P.) reviewed the new pump's mechanics with the patient, who had a 26-year history of Type 1 diabetes mellitus, and supervised the patient's programming of the pump. At bedtime, a blood sugar of > 250 mg/dL prompted the patient to give herself insulin via the pump. The next morning, she was treated at the emergency department for diabetic ketoacidosis. CASE ANALYSIS: The pump had been improperly primed, resulting in no insulin delivery. The incident also reflected the absence of a fail-safe mechanism(s) on the pump to alert the user to the improper priming and inappropriate handoff of the patient's care. Unlike the old pump, the new pump did not require manual priming. The lack of delivery of insulin resulted in DKA, a potentially life-threatening complication of diabetes. A root cause analysis suggested several important safety issues, including skipping of steps on the patient training checklist and other shortcuts in patient training. DISCUSSION: The clinic developed policies and procedures, including mandatory formal training for each pump model by the certified pump trainer and for initiation of insulin pump therapy. This case illustrates the importance of a structured device selection process, provider education, patient education, and monitoring for safety and effectiveness of technological devices in care.

Opioid analgesics in the substance abuser: pros and cons.

The pros and cons of using opioid analgesics to help manage pain in patient with a history of substance abuse are presented. Topics discussed include ethical constructs, efficacy, and safety relating to the use of opioids in patients with substance abuse histories.

Personal digital assistant-based drug information sources: potential to improve medication safety.

OBJECTIVES: This study compared the potential for personal digital assistant (PDA)-based drug information sources to minimize potential medication errors dependent on accurate and complete drug information at the point of care. METHODS: A quality and safety framework for drug information resources was developed to evaluate 11 PDA-based drug information sources. Three drug information sources met the criteria of the framework: Eprocrates Rx Pro, Lexi-Drugs, and mobileMICROMEDEX. Medication error types related to drug information at the point of care were then determined. Forty-seven questions were developed to test the potential of the sources to prevent these error types. Pharmacists and physician experts from Creighton University created these questions based on the most common types of questions asked by primary care providers. Three physicians evaluated the drug information sources, rating the source for each question: 1=no information available, 2=some information available, or 3 = adequate amount of information available. RESULTS: The mean ratings for the drug information sources were: 2.0 (Eprocrates Rx Pro), 2.5 (Lexi-Drugs), and 2.03 (mobileMICROMEDEX). Lexi-Drugs was significantly better (mobileMICROMEDEX t test; P=0.05; Eprocrates Rx Pro t test; P=0.01). CONCLUSION: Lexi-Drugs was found to be the most specific and complete PDA resource available to optimize medication safety by reducing potential errors associated with drug information. No resource was sufficient to address the patient safety information needs for all cases.

Chronic arthritis pain management with topical morphine: case series.

Chronic pain is a major health problem in the United States affecting 50 to 75 million Americans. The extent of pain encountered with chronic disease states may impact an individual's quality of life. Morphine is the drug of choice for severe pain. The primary purpose of the study was to determine analgesic response with the use of topical morphine to control chronic pain in a series of patients with arthritis pain. The second purpose was to detect the presence of morphine in the urine following topical administration and subsequently conclude that there had been systemic absorption of the drug. Three patients were prescribed topical morphine for chronic pain and were followed over the course of several weeks. Each patient was instructed to record the date and time of the topical morphine applications. When each patient had achieved a satisfactory level of pain control a 24-hour urine collection was obtained and taken to a laboratory for analysis. All patients reported a satisfactory degree of pain relief following topical application of morphine. The urine analysis confirmed the presence of morphine in the 24-hour samples. This analysis confirms systemic absorption of the morphine across intact skin; however the results cannot be used to quantify the degree of systemic absorption. Results of the study indicate that the use of topical morphine is effective in controlling chronic pain and topical morphine is absorbed systemically in the body.

American society of health-system pharmacists' pain management network.

The American Society of Health-System Pharmacists' (ASHP) Pain Management Network is one of several informal networking groups of pharmacist practitioners who specialize in a clinical practice area. Pharmacy practitioners are showing an increased interest in the management of pain because of expanding clinical roles, the Joint Commission on Accreditation of Health Care Organizations' development of pain management standards, and involvement with performance improvement and quality initiatives. The Pain Management Network is one of the American Society of Health-system Pharmacists (ASHP) Section of Clinical Specialists and Scientists specialty practice networks. The Network serves as an informal venue for practitioners interested in pain management to gather and share information. Pain Management Network Assemblies are held at each ASHP national meeting. Practitioners communicate between meetings via the Section's e-mail list server. Pharmacists who participate in the Pain Management Network have a variety of roles in both acute and chronic pain management. Their roles may be consultative in nature or they may be involved in the actual medication management as part of a collaborative drug therapy management agreement with a physician. Pharmacists are involved with acute pain, cancer-related pain, and chronic nonmalignant pain management. Current issues involve education of pharmacy students and practicing pharmacists as well as the use of meperidine as an analgesic agent. Compounding of non-sterile drugs for intraspinal use is another current issue. Access to evidence-based pain management resources may be difficult to locate and access but is essential to good pain management. The ASHP Pain Management Network has proven to be a valuable way for participants to gather and exchange new information and share in their clinical practice experiences.