Analysis of medication-related triggers to determine adverse drug events.

PURPOSE: Voluntary event reporting systems continue to be the most common method used to identify adverse events in most US hospitals; however, this method fails to capture more than 90% of adverse drug events (ADEs). The purpose of this study is to examine which medication-related triggers have the highest positive predictive values (PPV) for detecting ADEs at a large academic medical centre. METHODS: A 1-year, single-centre, retrospective quality improvement study was conducted to assess the PPV of four medication-related triggers: flumazenil, naloxone, glucose <70 mg/dL or dextrose 50%. Retrospective chart review was conducted on a random sample of eligible patients to establish if an ADE occurred and determine its preventability. Assessed triggers were also compared against the hospital's voluntary event reporting system to determine whether the events were previously reported. RESULTS: A total of 161 triggers were reviewed. PPV values for detection of ADEs were 0.55, 0.58, 0.76 and 0.68 for flumazenil, naloxone, glucose <70 mg/dL and dextrose 50%, respectively. PPV values for detection of preventable ADEs were 0.09, 0.16, 0.32 and 0.34 for flumazenil, naloxone, glucose <70 mg/dL and dextrose 50%, respectively. Of the 107 ADEs identified, three events were reported through the hospital's voluntary event reporting system (2.8%). CONCLUSIONS: Trigger tools successfully detected both preventable and non-preventable ADEs. Events detected using trigger tools are unlikely to be reported through voluntary event reporting systems; therefore, trigger tools can serve as a useful adjunct for adverse event detection.

Medication Errors in Overweight and Obese Pediatric Patients: A Narrative Review.

BACKGROUND: The childhood obesity epidemic in the United States has increased utilization of health care and prescribing of medications in overweight and obese children, yet it is unclear whether this has led to more medication errors. The objective of this study was to review all available literature on incidence and types of medication errors in overweight and obese children. METHODS: A search of MEDLINE, Embase, and Scopus databases was conducted for all studies and oral abstracts through December 2020 reporting medication errors in overweight or obese children aged ≤ 18 years. All studies were identified and extracted via a Covidence database. Two reviewers independently reviewed studies and rated the methodologic quality of those included per GRADE (Grading of Recommendations, Assessment, Development and Evaluations) criteria. RESULTS: The search identified 1,016 abstracts from databases. Following review, full text was obtained for 146 articles, of which 141 were excluded. A total of 5 studies met criteria for inclusion and described dosing errors of antimicrobials, anesthetics, and paracetamol in overweight and obese pediatric patients. Two of the 5 studies compared medication errors in obese to nonobese children, and both found that medication errors (both over- and underdosing) were generally more common among obese children. The identified reasons for medication errors included incorrect dosing weight, incorrect dosing strategy, over- and underdosing with weight-based and flat-fixed dosing, and inapposite use of age-based dosing schemas. CONCLUSION: There is a paucity of patient safety evidence available evaluating medication use in overweight and obese children and associated medication errors. Overweight and obese children may be at increased risk of medication errors, although the clinical significance of this is unknown.

Use of failure modes and effects analysis to mitigate potential risks prior to implementation of an intravenous compounding technology.

PURPOSE: The purpose of this study was to identify potential failure points in a new chemotherapy preparation technology and to implement changes that prevent or minimize the consequences of those failures before they occur using the failure modes and effects analysis (FMEA) approach. METHODS: An FMEA was conducted by a team of medication safety pharmacists, oncology pharmacists and technicians, leadership from informatics, investigational drug, and medication safety services, and representatives from the technology vendor. Failure modes were scored using both Risk Priority Number (RPN) and Risk Hazard Index (RHI) scores. RESULTS: The chemotherapy preparation workflow was defined in a 41-step process with 16 failure modes. The RPN and RHI scores were identical for each failure mode because all failure modes were considered detectable. Five failure modes, all attributable to user error, were deemed to pose the highest risk. Mitigation strategies and system changes were identified for 2 failure modes, with subsequent system modifications resulting in reduced risk. CONCLUSION: The FMEA was a useful tool for risk mitigation and workflow optimization prior to implementation of an intravenous compounding technology. The process of conducting this study served as a collaborative and proactive approach to reducing the potential for medication errors upon adoption of new technology into the chemotherapy preparation process.

Pharmacokinetic simulation of fatal carbamazepine intoxication in 23-month old child following phenytoin discontinuation.

The antiepileptic, carbamazepine, is extensively metabolized via hepatic enzymes in the cytochrome P450 family and is therefore subject to a myriad of drug interactions. Concomitant administration with phenytoin enhances carbamazepine metabolism thus reducing serum concentrations and necessitating the use of a higher maintenance dose. Removal of phenytoin therapy in the absence of anticipatory dose adjustments and careful monitoring of serum concentrations may result in catastrophic outcomes. Reported herein are the events leading to the death of a 23-month old child who suffered a fatal carbamazepine overdose following withdrawal of phenytoin therapy.