Liver Enzymes After Acetaminophen Error in Critically Ill Children: A Cohort Study

ObjectivesDrug-associated harm is common but difficult to detect in the hospital setting. In critically ill children, we sought to evaluate drug-associated hepatic injury following enteral acetaminophen error; defined as acetaminophen dosing that exceeds daily maximum recommendations.DesignRetrospective cohort study.SettingTwo pediatric intensive care units within a pediatric hospital center.PatientsChildren (<18 years of age) admitted to the pediatric and cardiac intensive care unit between January 2008 and January 2018, and receiving enteral acetaminophen. We defined acetaminophen dosing error as exceeding daily acetaminophen dosing by > 10% the upper limit of maximum recommended dose for weight and age (>82.5mg/kg/day or > 4400mg/day).Main ResultsWe included 14,146 admissions, who received 147,485 doses of acetaminophen. Acetaminophen dosing errors occurred 1 in every 9.5 patient-days on acetaminophen. ALT and AST decreased significantly over the course of ICU admission (p<0.0001). In patients with acetaminophen errors, ALT and AST measured in the 24 to 96 hours post error were not significantly different than when measured outside this window. A sensitivity analysis using >100 mg/kg/day as the upper daily acetaminophen error cut-off did not reveal any subsequent significant increase in ALT or ALT in the 24 to 96-hour post-error window, compared to measurements taken outside the window.ConclusionsAlthough the administration of acetaminophen in critically ill children frequently exceeds the daily recommended limit and vigilance is needed, we did not find any associated increase in liver transaminases following acetaminophen errors.

Increasing the Dosing Accuracy of Magnetodynamic Foundry Equipment

Introduction. The problem of combining continuous monitoring of the main informative process parameters (mass, temperature, melt consumption) and control of the pouring process is relevant for almost all filling devices today.Problem Statement. The development of pouring accuracy methods, particularly for small-dose pouring is an important task for the foundry industry.Purpose. The purpose is to study the dependences of the flow characteristics of the magnetodynamic equipment on the supplied voltage in various conditions of its operation.Materials and Methods. Physical modelling has been applied for the study of dosing accuracy for small doses in the range of 1.5—3 kg.Results. The coefficient of the numerical dependence of instantaneous mass flow consumption of a modeling fluid in the trough on the instantaneous mass of a modeling fluid in the trough has been established based on experimental studies with the use of a physical model of magnetodynamic device (MDD). The studies of filling doses within the range from 1.5 to 3 kg have shown that this coefficient corresponds to the range of the electromagnet supply voltage from 12.3 to 16.3 V. There have been determined the efficient range of the poured-metalmass to instantaneous-mass-flow-consumption ratio in the course of casting (2.20—2.25) and the corresponding range of the MDD electromagnet supply voltage to minimize the effect of jet pulsations on the dosing accuracy byreducing their amplitude. The dosing error does not exceed 1.5% by dose weight in the case of pouring small portions (1.5—3 kg).Conclusions. A new technical solution for MDD with an inclined weighting trough of a conventional design has been developed based on the electromagnetic transfer of a force proportional to the instantaneous melt massin the trough. The implementation of this solution makes it possible to reduce the number of strain gauge power sensors for the instantaneous measurement of the melt mass, from four sensors installed under the melting pot of the MDD prototype to one placed directly under the trough.

Neonatal Dhatura like poisoning - A premedication error in neonatal anesthesia

Overdosing of drugs sometimes produce fatal consequences. We report such a case of premedication dosing error in neonates with Glycopyrrolate leading to central anticholinergic syndrome (CAS) as in Dhatura poisoning. Accidental overdosing with glycopyrrolate resulted in symptoms like tachycardia, tachypnea, shock, hyperpyrexia, irritability and excessive crying. These symptoms resolved with symptomatic treatment. Errors can occur at any step of the path from drug prescription to administration. Medication errors are common and it should be immediately suspected in neonates with abnormal symptoms after injecting some drug, so that early diagnosis and treatment can be started timely. Identifying such medication errors is a challenge in neonatal care and should be a priority among caregivers in order to prevent future incidents and for patients’ safety.

Can use of pictograms reduce liquid medication administration errors by mothers? An interventional study

Background Liquid medication dosing errors (LMDE) made by caregivers affect treatment in children, but this is not a well-studied topic in many low-and middle-income countries including in India. Methods An intervention study was conducted among mothers attending a pediatric outpatient clinic of a tertiary care setting in Ujjain, India. The mothers randomly measured 12 volumes of a paracetamol liquid preparation by using a dropper (0.5 and 1 mL), measuring cup (2.5 and 5 mL), and calibrated spoon (2.5 and 5 mL) each with two instructions—oral-only measurement session (OMS) and oral plus pictogram measurement session (OPMS, the intervention). The main outcome was dosing error prevalence. The effectiveness of the intervention was assessed by measuring effect size. Risk factors for maximum LMDE were explored using backward multivariate logistic regression models. A P value of < 0.05 was considered statistically significant. Results In total, 310 mothers [mean (± SD) age, 30.2 (± 4.18) years] were included. LMDE prevalence in the OMS versus OPMS for dropper 0.5 mL was 60% versus 48%; for l mL dropper was 63% versus 54%; for 2.5 mL cup 62% versus 54%; for 2.5 calibrated spoon 66% versus 59%; 5 mL cup 69% versus 57%; and 5 mL calibrated spoon 68% versus 55%. Comparing OMS with OPMS, underdosing was minimum with the calibrated spoon for 2.5 mL (OR 4.39) and maximum with the dropper for 1 mL (OR 9.40), and overdosing was minimum with the dropper for 0.5 mL (OR 7.12) and maximum with the calibrated spoon for 2.5 mL (OR 13.24). The effect size (dCohen) of the intervention OPMS was 1.86–6.4. Risk factors for the most prevalent dosing error, that is, with the calibrated spoon for 2.5 mL, were increasing age of the mother (aOR 1.08; P = 0.026) and nuclear family (aOR 2.83; P = 0.002). The risk of dosing errors decreased with higher education of the mothers. Conclusions Pictograms can effectively minimize LMDE even in less educated mothers.

Antimicrobial Dosing Error in Intermittent & Continuous Hemodialysis

Antibiotic drugs are the most frequently prescribed medications among hospitalized patients for life-saving purposes, mainly in immunocompromised patient, like in patient with end stage renal disease on hemodialysis (HD) or those who had documented bacterial infection. Antibiotics disposition and their pharmacokinetics and pharmacodynamics properties are affected in hemodialysis patient which increases the number of antibiotics dosing errors. Several epidemiological studies found that the majority of medication error related to antibiotics occurred during the prescribing phase (30.8%). However, there is missing data about the prevalence of errors in antibiotics dosing in HD patients.

Challenges with Measurement and Transcription of Patient Height: An Analysis of Patient Safety Events in Pennsylvania Related to Inaccurate Patient Height

An accurate patient height is necessary to calculate certain measurements (e.g., body surface area [BSA]) and lab values (e.g., creatinine clearance [CrCl]), which may be needed to assess renal, cardiac, and lung function and to calculate accurate medication doses. We queried the Pennsylvania Patient Safety Reporting System (PA-PSRS) and identified 679 event reports related to an inaccurate patient height. All events were classified by the reporting facility as incidents, meaning that the patient did not sustain an unanticipated injury or require the delivery of additional healthcare services. The most common care area group where an event occurred was outpatient/clinic (35.8%; 243 of 679). Events were categorized as being related to an error in transcription (72.5%; 492 of 679) or measurement (7.4%; 50 of 679), and the remainder were categorized as etiology of error unclear (20.2%; 137 of 679). The most common transcription errors were the use of the wrong unit of measurement, the transposition of another measurement with height, and typographical errors. Inaccurate patient heights most often led to errors in calculation of medication doses or laboratory values. The most common medication class involved in a dosing error was cancer chemotherapy. In order to ensure accuracy of patient height measurements, patients should be measured at the beginning of every healthcare encounter, units of measurement should be consistent from measurement to transcription into the electronic medical record, and estimated patient height should never be relied upon or recorded.

METABOLOMICS REVEALS FIVE ENDOGENOUS BIOMARKERS IN HUMAN URINE AND PLASMA TO PREDICT CYP2D6 ACTIVITY

Background and Purpose: Individualized assessment of the activity of cytochrome P450 2D6 (CYP2D6), a highly variable drug-metabolizing enzyme, is performed through phenotyping during which a probe drug is administered to measure the enzyme’s activity. In order to avoid any iatrogenic harm (allergic drug reaction, dosing error) related to the probe drug, the development of non-invasive tools for real-time phenotyping of CYP2D6 could significantly contribute to the expansion of precision medicine in clinical practice. This study focuses on the identification of endogenous markers of the CYP2D6 enzyme in human biofluids using a liquid chromatography (LC)-high-resolution mass spectrometry (HRMS)-based metabolomics approach. Experimental Approach: Data from a control session were compared to data from an inhibition session. Before the latter, healthy volunteers (extensive and ultrarapid metabolizers) received a daily dose of paroxetine 20 mg over seven days. CYP2D6 genotyping and phenotyping, using single oral dose of dextromethorphan 5 mg, were also performed in all participants. Key Results: In CYP2D6 extensive and ultrarapid metabolizers (n = 37), mean relative intensities of five features were significantly reduced during the inhibition session compared to the control session (fold changes ≤ 0.67, FDR-adjusted P < 0.0001). Furthermore, mean relative intensities of these candidates were significantly higher in the CYP2D6 extensive-ultrarapid metabolizer group (n = 37) compared to the poor metabolizer group (n = 6) (fold changes ≤ 0.67, P < 0.0001). Conclusion and Implications: The applied untargeted metabolomics strategy was able to identify five CYP2D6 endogenous metabolites, a promising discovery for non-invasive phenotyping and personalised medicine.

Mannitol Dosing Error during Pre-neurosurgical Care of Head Injury: A Neurosurgical In-Hospital Survey from Ibadan, Nigeria

Objectives Inappropriate use of mannitol is a medical error seen frequently in pre-neurosurgical head injury (HI) care that may result in serious adverse effects. This study explored this medical error amongst HI patients in a Nigerian neurosurgery unit. Methods We performed a cross-sectional analysis of a prospective cohort of HI patients who were administered mannitol by their initial non-neurosurgical health care givers before referral to our center over a 22-month period. Statistical Analysis A statistical software was used for the analysis with which an α value of <0.05 was deemed clinically significant. Results Seventy-one patients were recruited: 17 (23.9%) from private hospitals, 13 (18.3%) from primary health facilities (PHFs), 20 (28.2%) from secondary health facilities (SHFs), and 21 (29.6%) from tertiary health facilities (THFs). Thirteen patients (18.3%) had mild HI; 29 (40.8%) each had moderate and severe HI, respectively. Pupillary abnormalities were documented in five patients (7.04%) with severe HI and neurological deterioration in two with mild HI.Mannitol administration was deemed appropriate in only 43.7% (31/71). Data on mannitol dosing in 60.6% (43/71) of the patients showed 8/43 (18.6%) receiving continuous 10% mannitol infusion. The remaining 35/43 received mannitol as a 20% solution but also showing dosing error in 62.9% (22/35): overdosing in 7/35 (20%), and nonbolus administration in 15/35 (42.9%). The distribution of the dosing error among the referring health facilities (all the 13 [100%] patients from private hospitals, 66.7% from PHF, 60% from SHF, and 45.5% from THF) showed a trend of better performance (p = 0.002) by the THFs. Conclusion Mannitol use is apparently fraught with an understudied medical error in the pre-neurosurgical care of the head injured.

Literature review of medication administration problems in paediatrics by parent/caregiver and the role of health literacy

ObjectiveTo identify studies that highlighted medication administration problems experienced by parents and children, which also looked at health literacy aspect using a validated tool to assess for literacy.Study designTen electronic databases were systematically searched and supplemented by hand searching through reference lists using the following search terms: (1) paediatric, (2) medication error including dosing error, medication administration error, medication safety and medication optimisation and (3) health literacy.ResultsOf the (1230) records screened, 14 studies were eligible for inclusion. Three analytical themes emerged from the synthesis. The review highlighted that frequencies and magnitudes of dosing errors vary by the measurement tools used, the dose prescribed and by the administration instruction provided. Parent’s sociodemographic, such as health literacy and language, is a key factor to be considered when designing an intervention aimed at averting medication administration errors at home. The review summarised some potential strategies that could help in reducing medication administration errors among children at home. Among these recommendations is to show the prescribed dose to the parents or young people along with the verbal instructions, as well as to match the prescribed dose with the measuring tool dispensed, to provide an explicit dose intervals and pictographic dosing instructions.ConclusionThe findings suggest that in order to optimise medication use by parents, further work is needed to address the nature of these issues at home. Counselling, medication administration instructions and measurement tools are some of the areas in addition to the sociodemographic characteristics of parents and young people that need to be considered when designing any future potential intervention aimed at reducing medication errors among children and young people at home.