Comparison of a metronome-guided prehospital medication infusion technique with standard calculation: a simulated randomized, controlled, cross-over study

Background Limited research regarding administration of timed medication infusions in the prehospital environment has identified wide variability with accuracy, timing, and overall feasibility. This study was a quality improvement project that utilized a randomized, controlled, crossover study design to compare two different educational techniques for medication infusion administration. We hypothesized that the use of a metronome-based technique would decrease medication dosage errors and reduce time to administration for intravenous medication infusions. Methods Forty-two nationally registered paramedics were randomized to either a metronome-based technique versus a standard stopwatch-based technique. Each subject served as a control. Subjects were asked to establish an infusion of amiodarone at a dose of 150 mg administered over 10 min, simulating treatment of a hemodynamically stable patient with sustained monomorphic ventricular tachycardia. Descriptive statistics and a repeated measures mixed linear regression model were used for data analysis. Results When compared to a standard stopwatch-based technique, a metronome-based technique was associated with faster time to goal (median 34 s [IQR, 22–54] vs 50 s; [IQR 38–61 s], P = 0.006) and fewer mid-infusion adjustments. Ease of use was reported to be significantly higher for the metronome group (median ranking 5, IQR 4–5) compared to the standard group (median ranking 2, IQR 2–3; P < 0.001). Conclusions Knowledge regarding a metronome technique may help EMS clinicians provide safe and effective IV infusions. Such a technique may be beneficial for learners and educators alike.

Comparison of a Metronome-guided Prehospital Medication Infusion Technique with Manual Calculation: A Simulated Randomized, Controlled, Cross-over Study

BackgroundLimited research regarding administration of timed medication infusions in the prehospital environment has identified wide variability with accuracy, timing, and overall feasibility. This study was a pragmatic, randomized, controlled, crossover study comparing two different techniques for medication infusion administration. We hypothesized that the use of a metronome-based technique would decrease medication dosage errors and reduce time to administration for intravenous medication infusions. Methods Forty-two nationally registered paramedics were randomized to either a metronome-based technique versus a standard stopwatch-based technique. Each subject served as a control. Subjects were asked to establish an infusion of amiodarone at a dose of 150 mg administered over 10 minutes, simulating treatment of a hemodynamically stable patient with sustained monomorphic ventricular tachycardia. Descriptive statistics and multiple linear regression were used for data analysis. Results When compared to a standard stopwatch-based technique, a metronome-based technique was associated with faster time to goal, fewer mid-infusion adjustments, and greater ease of use. Conclusions Use of a metronome technique for establishing medication infusion rates may help prehospital clinicians provide safer and more precise medication delivery.

Erros de dose de medicamento em unidade de urgência hospitalar

RESUMOObjetivo: analisar erros de dose de medicamentos endovenosos em um serviço de pronto-atendimento hospitalar. Método: trata-se de estudo quantitativo, transversal, envolvendo 139 doses de medicamentos. Coletaram-se os dados mediante observação não participante com um instrumento do tipo formulário. Realizou-se a análise e interpretação dos dados por meio da estatística descritiva e teste qui-quadrado. Resultados: evidenciou-se, quanto à classe farmacológica, que os analgésicos apresentaram a maior frequência (38,1%), seguidos por vitamínicos (33,8%) e antibióticos/antimicrobianos (17,3%). Verificou-se, ainda, que dentre 118 medicações que necessitaram de diluição, em 88 não ocorreu erro, sendo que 62 (70,5%) foram realizadas por acadêmicos de enfermagem. Sobressalta-se que nas 30 que tiveram erro, 70,0% foram efetuadas pelos acadêmicos de enfermagem e 30,0% pelos técnicos de enfermagem. Interrompeu-se em 64 (90,1%) a infusão ainda incompleta. Conclusão: observou-se alta frequência dos erros de dose, reiterando-se a necessidade de verificação constante das deficiências no sistema de medicação e no processo de trabalho da equipe de saúde. Projeta-se que estudos desse perfil poderão subsidiar políticas institucionais para segurança quanto ao uso dos medicamentos. Descritores: Erros de Medicação; Segurança do Paciente; Unidades Hospitalares; Uso de Medicamentos; Assistência Ambulatorial; Erros Médicos. ABSTRACT Objective: to analyze intravenous medication dosage errors in a hospital emergency service. Method: this is a quantitative, cross-sectional study involving 139 drug doses. Data were collected through non-participant observation with aid of a form. The data were analyzed and interpreted through descriptive statistics and the chi-square test. Results: the pharmacological class showed that analgesics presented the highest frequency (38.1%), followed by vitamins (33.8%) and antibiotics/antimicrobials (17.3%). It was also verified that out of 118 medications that required dilution, no error occurred in 88; and 62 (70.5%) were performed by nursing students. It is noteworthy that in the 30 medication administrations in which errors occurred, 70.0% were made by nursing students and 30.0% by nursing technicians. Infusions were interrupted before completion in 64 cases (90.1%). Conclusion: a high frequency of dosage errors was observed, reiterating the need for constantly checking the flaws in the medication system and in the work process of the health team. It is projected that studies of this type may subsidize institutional policies for safety regarding the use of medicines. Descriptors: Medication Errors; Patient Safety; Hospital Units; Use of Medications; Ambulatory Care; Medical Errors. RESUMEN Objetivo: analizar errores de dosis de medicamentos endovenosos en un servicio de pronta atención hospitalaria. Método: se trata de un estudio cuantitativo, transversal, involucrando 139 dosis de medicamentos. Se recolectaron los datos mediante observación no participante con un instrumento del tipo formulario. Se realizó el análisis e interpretación de los datos por medio de la estadística descriptiva y la prueba de chi-cuadrado. Resultados: se evidenció, en cuanto a la clase farmacológica, que los analgésicos presentaron la mayor frecuencia (38,1%), seguidos por vitaminas (33,8%) y antibióticos/antimicrobianos (17,3%). Se verificó, además, que entre 118 medicamentos que necesitaban de dilución, en 88 no ocurrió error, siendo que 62 (70,5%) fueron realizadas por académicos de enfermería. Se destaca que en las 30 que tuvieron error, el 70,0% fueron efectuadas por los académicos de enfermería y el 30,0% por los técnicos de enfermería. Se interrumpió en 64 (90,1%) la infusión aún incompleta. Conclusión: se observó una alta frecuencia de los errores de dosis, reiterándose la necesidad de verificación constante de las deficiencias en el sistema de medicación y en el proceso de trabajo del equipo de salud. Se proyecta que estudios de ese perfil podrán dar soporte a políticas institucionales para seguridad acerca del uso de los medicamentos. Descriptores: Errores de Medicación; Seguridad del Paciente; Unidades Hospitalarias; Utilización de Medicamentos; Atención Ambulatoria; Errores Médicos.

Preventing 10-fold Dosage Errors; Controlled Substances at Bedside or Procedural Area; Genvoya-Stribild Mix-up; Should Transdermal Fentanyl be Stocked in the ED?

These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them at your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the Institute for Safe Medication Practices (ISMP) Medication Errors Reporting Program. Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below. Errors, close calls, or hazardous conditions may be reported directly to ISMP through the ISMP Web site ( www.ismp.org ), by calling 800-FAIL-SAFE, or via e-mail at [email protected] . ISMP guarantees the confidentiality and security of the information received and respects reporters' wishes as to the level of detail included in publications.

Risks of Oral Methotrexate Administration in Outpatients

Methotrexate (MTX) is a cytostatic agent used in oncology. Because of its immunosuppressive properties, MTX is also used in autoimmune disorders. Low-dose MTX regimens in the treatment of rheumatoid arthritis and severe psoriasis are considered to be safe. However, pharmacovigilance centers warn of serious and even fatal incidents due to errors in oral MTX administration. The aim of this case series presentation was to identify the specific factors related to the development of adverse drug reactions (ADRs) induced by MTX. A prospective pharmacovigilance study was conducted at the Clinic of Dermatology, University Hospital, Stara Zagora. We report 3 cases of patients with psoriasis vulgaris in which severe haematological abnormalities associated with previous administration of MTX were detected during hospitalization. A 73-year old female with malaise, vomiting and oral ulcers who had taken approximately 120 mg MTX was found to have pancytopenia. A 59-year old male hospitalized for psoriatic erythroderma who had erroneously taken 10 mg MTX daily instead of weekly for 8 days, was diagnosed with bicytopenia and toxic hepatitis. An 88-year old male with psoriatic arthritis presented with aphthous stomatitis, erosive crusted lesions, ecchymoses and aplastic anemia 2 weeks after treatment with 12.5 mg MTX once weekly plus i.m. Movalis®, followed by Diclophenac Duo®. The main predisposing factors for the development of these ADRs were patient-related dosage errors and concomitant administration of NSAIDs. Safe use of oral MTX requires clear dosing instructions and strict patient compliance. Potential drug interactions of MTX with other drugs should also be considered.

A 5-year Study of Systemic Reactions Using both Shared and Patient-Specific Vaccines

The safety of shared specific vaccines (SSVs) has been questioned by some experts. The purpose of this study was to evaluate the safety of SSVs. Details of systemic allergic reactions after subcutaneous immunotherapy injections were captured on a standardized form from July 2005 to July 2010. Patient records were evaluated for factors that might be associated with increased rate of systemic reactions and, in addition, were examined for any errors. Systemic reaction rates (SRRs) using a combination of shared and patient-specific vaccines (PSVs) were similar to previously reported studies (0.23 reactions per 100 shots). There were no systemic reactions resulting from errors where the incorrect shared allergen was administered, but we did note one reaction after an erroneously administered PSV. There were two dosage errors associated with both shared and patient-specific immunotherapy. Most reactions were mild to moderate (World Allergy Organization grade, 1 or 2). Severe reactions with 911 activations were noted in six patients. Thirty percent of reactions occurred out of the office and the average time to reaction was 48 minutes. Epinephrine was administered in only 60% of patients. Epicutaneous reactivity to mites, cats, dogs, and pollen but not mold occurred significantly more in reactors. Differences in SRRs were encountered between satellite offices. Using a combination of SSV and PSV, SRRs were similar to previously reported studies; moreover, no systemic reactions occurred where a SSV was erroneously administered. SRR surveillance is a useful safety tool.