Hospital Medications errors!

[Nano1971]

Hi..Its a very difficult topic when we as pharmacist face a Medicatons errors at a Hospital setting which is relatively so busy (IV, order entery,filtering duplicates medicatons shortages,and so on..) how do we make the best of practice minmizing such Med errors any tips or advise appreciated!?

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[gwarm01]

Never do something unless you are absolutely sure you understand what you are doing.

 

[Sparda29]

My 0.02 based on a medication error that happened with me.

Don't trust the allergy acknowledgment screen in the EMR/CPOE system. Quite a lot of prescribers just click through the hard stops for allergies without reading what the computer is trying to tell them. PA ordered enalaprilrat when the patient has a documented allergy to ace inhibitors. PA clicks "prescriber is aware of allergy". I verify the order since the prescriber signed off that they are aware of allergy and dispense the medication. Nurse sees that the prescriber has signed off on the allergy notification, and pharmacy has also dispensed it with the prescriber aware alert and administers. Patient has an anaphalyctic reaction.

 

[headortail]

My 0.02 based on a medication error that happened with me.

Don't trust the allergy acknowledgment screen in the EMR/CPOE system. Quite a lot of prescribers just click through the hard stops for allergies without reading what the computer is trying to tell them. PA ordered enalaprilrat when the patient has a documented allergy to ace inhibitors. PA clicks "prescriber is aware of allergy". I verify the order since the prescriber signed off that they are aware of allergy and dispense the medication. Nurse sees that the prescriber has signed off on the allergy notification, and pharmacy has also dispensed it with the prescriber aware alert and administers. Patient has an anaphalyctic reaction.

What happened in your case?

In these situations where anaphylaxis is possible, or if rxn is unclear, I typically try to view all hx in the past, to see if they've ever gotten it before. But if RN documents allergy as "cough", I really won't look further and just think of it as intolerance.

To reduce errors, if at all possible I glance at my profile one time before exiting, to make sure there are no gross errors I or someone else made that was overlooked while verifying individual orders.

I keep in mind that if I verify something, I assume it will be given. That and to trust nobody. Not your most careful pharmacist. Not your brightest pharmacist. Not your nicest or most competent MD. Everyone can make mistakes and it doesn't mean they're bad practitioners. There are many factors that can create an error prone environment.

 

[Sparda29]

What happened in your case?

In these situations where anaphylaxis is possible, or if rxn is unclear, I typically try to view all hx in the past, to see if they've ever gotten it before. But if RN documents allergy as "cough", I really won't look further and just think of it as intolerance.

To reduce errors, if at all possible I glance at my profile one time before exiting, to make sure there are no gross errors I or someone else made that was overlooked while verifying individual orders.

I keep in mind that if I verify something, I assume it will be given. That and to trust nobody. Not your most careful pharmacist. Not your brightest pharmacist. Not your nicest or most competent MD. Everyone can make mistakes and it doesn't mean they're bad practitioners. There are many factors that can create an error prone environment.

Patient survived. Patient had come in for hypertensive emergency and this was ordered by the ED physician assistant.

 

[samven582]

My 0.02 based on a medication error that happened with me.

Don't trust the allergy acknowledgment screen in the EMR/CPOE system. Quite a lot of prescribers just click through the hard stops for allergies without reading what the computer is trying to tell them. PA ordered enalaprilrat when the patient has a documented allergy to ace inhibitors. PA clicks "prescriber is aware of allergy". I verify the order since the prescriber signed off that they are aware of allergy and dispense the medication. Nurse sees that the prescriber has signed off on the allergy notification, and pharmacy has also dispensed it with the prescriber aware alert and administers. Patient has an anaphalyctic reaction.

I still would have called, verify and documented. Did this happen overnight?

 

[PharmDBro2017]

I still would have called, verify and documented. Did this happen overnight?

While I also call on things like this... I recently had an encounter with an ER physician that went like this:
-Pt had documented penicillin allergy (hives/throat swelling) and they ordered some cephalosporin (maybe it was rocephin iirc)
-I called the ER and spoke to the nurse of that patient. "Hey this patient has a penicillin allergy, is Dr. BlahBlah aware and still wanting to give this Rocephin shot?"
-I can hear the nurse ask the ER doc word for word what I just asked her; his response was "Are you fuking serious? Who the fuk is working in pharmacy tonight?"
-"Ok then... thanks", and I verified it with a nice i-vent to it.

While I understand the chance of cross-reactivity is rather low (5-10% maybe from what I've read), it still is our job to call/verify/document the physician wanted it regardless of allergy potential, and i-vent the entire thing... but damn I wanted to walk down there and give him a stone cold stunner. Edit: I guess my point here is that our job is to catch errors and prevent complications, and the blatant disrespect of that physician when I was just doing my job... it gets to me. So much for advocating for our patients.

 

[owlegrad]

While I also call on things like this... I recently had an encounter with an ER physician that went like this:
-Pt had documented penicillin allergy (hives/throat swelling) and they ordered some cephalosporin (maybe it was rocephin iirc)
-I called the ER and spoke to the nurse of that patient. "Hey this patient has a penicillin allergy, is Dr. BlahBlah aware and still wanting to give this Rocephin shot?"
-I can hear the nurse ask the ER doc word for word what I just asked her; his response was "Are you fuking serious? Who the fuk is working in pharmacy tonight?"
-"Ok then... thanks", and I verified it with a nice i-vent to it.

While I understand the chance of cross-reactivity is rather low (5-10% maybe from what I've read), it still is our job to call/verify/document the physician wanted it regardless of allergy potential, and i-vent the entire thing... but damn I wanted to walk down there and give him a stone cold stunner. Edit: I guess my point here is that our job is to catch errors and prevent complications, and the blatant disrespect of that physician when I was just doing my job... it gets to me. So much for advocating for our patients.

Sorry you had that experience, that doc sounds like a jerk.

As for the actually cross-reactivity, according to Pharmacists Letter it is:

• approximately 0.1% for patients without skin test-confirmed penicillin allergy. (most patients according to owlegrad)
• approximately 0.1% for those with mild reactions to penicillin.
• approximately 2% for patients with a positive penicillin skin test.

Personally I would not call for that. But I also think it is never wrong to err on the side of caution and would respect someone who did call, as long as they are informed about the relative risk involved.

 

[PolarPop]

Sorry you had that experience, that doc sounds like a jerk.

As for the actually cross-reactivity, according to Pharmacists Letter it is:

• approximately 0.1% for patients without skin test-confirmed penicillin allergy. (most patients according to owlegrad)
• approximately 0.1% for those with mild reactions to penicillin.
• approximately 2% for patients with a positive penicillin skin test.

Personally I would not call for that. But I also think it is never wrong to err on the side of caution and would respect someone who did call, as long as they are informed about the relative risk involved.

I agree the rate is <1% but this is anaphylaxis and should be called for if you have no evidence of them tolerating other beta lactams. Especially since the CDC specifically recommends alternatives to ceftriaxone in patients with type 1 hypersensitivity reactions to penicillin (assuming this is for gonorrhea?).

 

[PharmDBro2017]

Sorry you had that experience, that doc sounds like a jerk.

As for the actually cross-reactivity, according to Pharmacists Letter it is:

• approximately 0.1% for patients without skin test-confirmed penicillin allergy. (most patients according to owlegrad)
• approximately 0.1% for those with mild reactions to penicillin.
• approximately 2% for patients with a positive penicillin skin test.

Personally I would not call for that. But I also think it is never wrong to err on the side of caution and would respect someone who did call, as long as they are informed about the relative risk involved.

Interesting. Post the link for that please?


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[owlegrad]

Interesting. Post the link for that please?


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It’s behind a pay wall (PL isn’t free). But it is a really interesting article. I will see if I can PM you a PDF when I get home.

 

[PharmDBro2017]

Wayyyyy less than 5% bro. Probably why you got the response from that doc.

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We were taught that of the people with true penicillin allergies (obviously a very small %), only ~5% of those would have a cross reactivity to a cephalosporin. That’s where I came up with it... haven’t researched any lately though.


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[PolarPop]

We were taught that of the people with true penicillin allergies (obviously a very small %), only ~5% of those would have a cross reactivity to a cephalosporin. That’s where I came up with it... haven’t researched any lately though.


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Studies before the 1980s found cross reactivity rates that high but this is also the period of time when cephalosporins were contaminated with small amounts of penicillin. It’s really sad that they are still teaching 5-10% in school, you must have learned from a dinosaur.

I want to say that there is a paper somewhere looking at cross-reactivity rates pre-1980s compared to after that but I can’t remember at the moment.

 

[owlegrad]

Interesting. Post the link for that please?


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Here is the link: Login

 

[sakigt]

While I also call on things like this... I recently had an encounter with an ER physician that went like this:
-Pt had documented penicillin allergy (hives/throat swelling) and they ordered some cephalosporin (maybe it was rocephin iirc)
-I called the ER and spoke to the nurse of that patient. "Hey this patient has a penicillin allergy, is Dr. BlahBlah aware and still wanting to give this Rocephin shot?"
-I can hear the nurse ask the ER doc word for word what I just asked her; his response was "Are you fuking serious? Who the fuk is working in pharmacy tonight?"
-"Ok then... thanks", and I verified it with a nice i-vent to it.

While I understand the chance of cross-reactivity is rather low (5-10% maybe from what I've read), it still is our job to call/verify/document the physician wanted it regardless of allergy potential, and i-vent the entire thing... but damn I wanted to walk down there and give him a stone cold stunner. Edit: I guess my point here is that our job is to catch errors and prevent complications, and the blatant disrespect of that physician when I was just doing my job... it gets to me. So much for advocating for our patients.

Heres the problem with calling on that. What are they going to do instead? Levaquin? With tendon rupture and drug interactions? If its for a UTI Bactrim? With terrible coverage and SJS?

To be fair, the throat swelling is a little scary. Alternatively, Id tell the RN: "RN, this patient has history of throat swelling, Rocpehin has a very very <1% chance of causing the same reaction but I just wanted to let you know so you could carefully monitor the patient."

 

[PharmDBro2017]

Heres the problem with calling on that. What are they going to do instead? Levaquin? With tendon rupture and drug interactions? If its for a UTI Bactrim? With terrible coverage and SJS?

To be fair, the throat swelling is a little scary. Alternatively, Id tell the RN: "RN, this patient has history of throat swelling, Rocpehin has a very very <1% chance of causing the same reaction but I just wanted to let you know so you could carefully monitor the patient."

Macrobid? Fosfomycin?

I’ve never seen Bactrim induce SJS, tbh. You? And I thought that was mostly in immunocompromised patients.

I wouldn’t do a FQ unless it was complicated UTI or had no other options.


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[nasacort24hr]

interesting....so do you guys all call for cross reactivity of allergy for penicillin, cephalosporin, carbapenem, monobactam? What about codeine, norco, percocet, morphine, dilaudid?

 

[owlegrad]

interesting....so do you guys all call for cross reactivity of allergy for penicillin, cephalosporin, carbapenem, monobactam? What about codeine, norco, percocet, morphine, dilaudid?

Sadly my company (and more to the point, bosses) require me to call on all allergy alerts. Although I actually refuse to call on the PCN/cephalosporins cross-reactivity issue and so far they haven't fired me.

But any opioids must have written clarification from the prescriber if the patient reports an allergy to any other opioid. So annoying and time wasting.

 

[PharmDBro2017]

interesting....so do you guys all call for cross reactivity of allergy for penicillin, cephalosporin, carbapenem, monobactam? What about codeine, norco, percocet, morphine, dilaudid?

We were told that we have to call on PCN/betalactam allergy and make sure the physician wants it.

Morphine/codeine allergy is another call.

Hydrocodone/Hydromorphone allergy is another call.




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[FarmTheMine]

One of the problems that I find with med error reporting in the hospital system is that although there are a number of valid medication errors that get reported, there is a significant amount of "errors" reported that are merely people tattle-taling on others.

 

[gwarm01]

One of the problems that I find with med error reporting in the hospital system is that although there are a number of valid medication errors that get reported, there is a significant amount of "errors" reported that are merely people tattle-taling on others.

I've had "errors" reported that were legitimate therapies backed up by research. It felt like the med error person always seemed to believe what some nurse reported.

 

[nasacort24hr]

Medication errors will happen in mostly any places with smart and good staffs. Its the culture that the place have that will make use of errors reported, to learn from it and improve the system to prevent similar errors from happening. Places I've seen are with leaderships that will just discipline staffs for errors, using this approaches scares people to report things. I don't understand why leaderships tend to use this approach rather use just culture.

 

[nasacort24hr]

We were told that we have to call on PCN/betalactam allergy and make sure the physician wants it.

Morphine/codeine allergy is another call.

Hydrocodone/Hydromorphone allergy is another call.




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It's tough. Some times calling to md and ask: pt has pcn allergy, are you sure you want to use meropenem / rocephine, etc? md will say---yeah, that's why i write the order, or "yes, there is low chance of cross-reactivity, why you call for this? we use it all the time on pcn allergic pt."

 

[Rockinacoustic]

The worst way to intervene on something is to call the prescriber and say "Hi Dr. I noticed ____ . Are you sure you want this?"

Do your homework and call with a back-up plan. Is the reaction a true allergy? Has the patient tolerated similar agents beforehand? Can something else be used for treatment or is a beta-lactam the preferred choice despite the chance of cross-reactivity.

Even if I'm in the main pharmacy and can't ask the patient myself I call the nurse and tell them what to ask on my behalf.

 

[smercer]

When I encounter patients with either opiate or PCN allergies to the med ordered, my first call is to the nurse. A lot simpler to have the nurse confirm with the patient or their family if they have ever had Keflex or Percocet before. If they cannot give me an answer, then I will check with the doc. 5% is low, but you gotta CYA.

 

[headortail]

The worst way to intervene on something is to call the prescriber and say "Hi Dr. I noticed ____ . Are you sure you want this?"

Do your homework and call with a back-up plan. Is the reaction a true allergy? Has the patient tolerated similar agents beforehand? Can something else be used for treatment or is a beta-lactam the preferred choice despite the chance of cross-reactivity.

Even if I'm in the main pharmacy and can't ask the patient myself I call the nurse and tell them what to ask on my behalf.

Yep. Always have a recommendation available. In some cases I don't (QTc is this, you sure you want that dofetilide, no I can't recommend another anti-arrhythmic for you I'm sorry) because I can't, but if at all possible I always try to recommend something to replace the thing I'm calling about.

These are the convos that make me cringe:

- Doc pt has PCN allergy you started Unasyn.
- OK... what else can I use to treat something intra-abdominal?
- Uh.....

If you have a doctorate degree, your answer should be better than "uh".

 

[Dalteparin]

interesting....so do you guys all call for cross reactivity of allergy for penicillin, cephalosporin, carbapenem, monobactam? What about codeine, norco, percocet, morphine, dilaudid?

Anaphylactic reactions to opiates seem to be pretty rare - most of the opioid reactions I see are things like "nausea" or "hallucinations" or "made me feel weird." But yes, if it was anaphylaxis and I couldn't tell if the patient had received other opiates before, I'd call.

As for beta-lactams, I call if it's anaphylaxis. But for the record, if I see a penicillin allergy in a patient > 70 years old, I take it with a grain of salt; these folks are more likely to have received formulations of penicillin that contained impurities, and so they may have been reacting to a contaminant instead of the drug.

 

[Nano1971]

Hi..a week ago while dosing Levaquin at my hospital during my review found that the RN.put incorrect paient weight and that made a difference in calculation in Crcl..my question is how sometimes an error like weight and Ht will mess up ...and how often while screening the profile will miss simple stuff that might be risky if not caught...!!!

 

[smercer]

Hi..a week ago while dosing Levaquin at my hospital during my review found that the RN.put incorrect paient weight and that made a difference in calculation in Crcl..my question is how sometimes an error like weight and Ht will mess up ...and how often while screening the profile will miss simple stuff that might be risky if not caught...!!!

Ideally they would be updating/checking weight daily (esp when most hospital beds can check weight with the push of a button), but nurses are typically taking care of several patients and I can see how errors like that could occur. Best you could do is just check older out patient notes that may list a weight to compare against. Also if you see a really low or high weight take the time to call the nurse and be sure the patient is really 300 kg.

 

[Robbin]

Pharmacist job is highly demanding on the basis of providing the right medicine as prescribed by the doctors. The medication errors are unacceptable because it can lead to destroy the branding and the license as well. You have to organize the work as per the requirement.