Voluntarily reported prescribing, monitoring and medication transfer errors in intensive care units in The Netherlands.

Background Medication errors occur frequently in intensive care units (ICU). Voluntarily reported medication errors form an easily available source of information. Objective This study aimed to characterize prescribing, monitoring and medication transfer errors that were voluntarily reported in the ICU, in order to reveal medication safety issues. Setting This retrospective data analysis study included reports of medication errors from eleven Dutch ICU's from January 2016 to December 2017. Method We used data extractions from the incident reporting systems of the participating ICU's. The reports were transferred into one database and categorized into type of error, cause, medication (groups), and patient harm. Descriptive statistics were used to calculate the proportion of medication errors and the distribution of subcategories. Based on the analysis, ICU medication safety issues were revealed. Main outcome measure The main outcome measure was the proportion of prescribing, monitoring and medication transfer error reports. Results Prescribing errors were reported most frequently (n = 233, 33%), followed by medication transfer errors (n = 85, 12%) and monitoring errors (n = 27, 4%). Other findings were: medication transfer errors frequently caused serious harm, especially the omission of home medication involving the central nervous system and proton pump inhibitors; omissions and dosing errors occurred most frequently; protocol problems caused a quarter of the medication errors; and medications needing blood level monitoring (e.g. tacrolimus, vancomycin, heparin and insulin) were frequently involved. Conclusion This analysis of voluntarily reported prescribing, monitoring and medication transfer errors warrants several improvement measures in these processes, which may help to increase medication safety in the ICU.

Free alpha-subunit and intact TSH secretion in vitro are closely associated in human somatotroph adenomas.

OBJECTIVE: GH-secreting pituitary adenomas frequently co-secrete prolactin and glycoprotein hormone alpha-subunit (alphaSU), but expression of additional hormones is considered unusual. The aim of this study was to establish the frequency with which acromegalic tumours secrete intact glycoprotein hormones LH, FSH and TSH, in comparison with other types of pituitary adenoma. DESIGN AND METHODS: Pituitary tumours were studied by cell culture, measuring the basal secretion of anterior pituitary hormones in vitro. Light microscopy was used to exclude tumours where normal pituitary tissue was present, and immunocytochemistry was employed to confirm the clinical diagnosis and for comparison with tissue culture data. RESULTS: TSH secretion was observed in vitro in 15/23 somatotroph adenomas, but from only 1/8 lactotroph, 4/29 null cell, 2/12 gonadotroph and 1/10 corticotroph adenomas; moreover, somatotroph adenomas secreted the largest amounts of TSH (P < 0.(001). Somatotroph adenomas also secreted LH (7/23) and FSH (2/23) but less frequently than gonadotroph adenomas. Immunocytochemistry demonstrated glycoprotein expression in somatotroph adenomas (LHbeta: 13%, FSHbeta: 26%, TSHbeta: 30%, alphaSU: 46%) more frequently than in lactotroph, corticotroph and null cell adenomas. A strong correlation was found between alphaSU secretion and TSH secretion in somatotroph adenomas (rho= 0.683, P < 0.001. CONCLUSIONS: TSHbeta is frequently expressed by somatotroph adenomas, often associated with alphaSU expression. Both GH and TSHbeta are dependent on the transcription factor, Pit-1, which is frequently expressed in somatotroph adenomas, although the expression of alphaSU requires an alternative explanation. Increased expression of alphaSU compared with TSHbeta may account for the secretion of free alphaSU by somatotroph adenomas.

Treatment of recurrent cytomegalovirus retinitis with the ganciclovir implant.

PURPOSE: To evaluate preoperative characteristics and outcome of the treatment of recurrent cytomegalovirus (CMV) retinitis with the ganciclovir implant. METHODS: Records of 54 patients with acquired immunodeficiency syndrome and active, previously treated CMV retinitis who received a ganciclovir implant in one (n = 31) or both (n = 23) eyes were reviewed. Entry criteria included prior insertion and removal of an indwelling catheter or failure to respond to tolerated doses of ganciclovir and foscarnet. Preoperative factors that might correlate with outcome were analyzed, including demographic factors, duration of human immunodeficiency virus disease and CMV retinitis, indications for surgery, prior anti-CMV treatment, and extent of retinitis. RESULTS: Forty-six patients completed 1 month of follow-up and were analyzed for outcome. Thirty-one (67.4%) had inactive retinitis at 1 month vs 15 (32.6%) with active retinitis, and they received a mean of 23.5 +/- 22.9 weeks of preoperative ganciclovir vs 58.0 +/- 52.0 weeks in patients with active retinitis (P = .003). Involvement of more than 25% of retinal area by CMV retinitis was also correlated with activity at 1 month (P < .001). Patients who received implants because of lack of venous access had a median time to progression of 8.0 +/- 3.0 months vs 2.0 +/- 1.2 months for patients who had inadequate response or intolerance to intravenous medication (P = .073). Patients with 6 months or less vs more than 6 months of preoperative ganciclovir treatment had progression at a median time of 8.0 +/- 1.7 months vs 2.0 +/- 0.3 months, respectively (P = .016). CONCLUSION: Longer duration of preoperative ganciclovir or larger area of CMV retinitis correlates with lower success of ganciclovir implant therapy for recurrent retinitis.

[A patient with lessened sensitivity to acenocoumarol during a period of enteral feeding]. / Een patiënt met verminderde gevoeligheid voor acenocoumarol tijdens gebruik van sondevoeding.

A 69-year-old man was operated on for a subdural haematoma which had developed during the use of acenocoumarol. Directly after the operation the patient was started on enteral feeding. The acenocoumarol was restarted at a later stage. The dose of acenocoumarol needed for an appropriate level of blood-dilution was twice as high during the period of enteral feeding than it had been preoperatively. After the transition from enteral feeding to oral feeding it was possible to lower the dose of acenocoumarol. The need for a higher dose was probably due to enhanced binding of the proteins in the enteral feeding. The patient was admitted to a nursing home. The combination of acenocoumarol and enteral feeding occurs frequently in patients being rehabilitated. It is important to monitor the blood-dilution when starting and stopping enteral feeding.