Pearls (and perils) of drug administration in the Emergency Department

1. Pearls (and perils) of drug administration in the Emergency Department Joshua Villarreal & Jennifer Knutson

2. Medication Errors • Affect up to 60% of Emergency Department (ED) patients 1Patanwala AE, Warholak TL, Sanders AB, et al. A prospective observational study of medication errors in a tertiary care emergency department. Ann Emerg Med. 2010;55:522-526.

3. Medication Errors • Errors occur during • Prescribing process: 82% • Administration process: 12% • Transcribing and monitoring: 6% 1Patanwala AE, Warholak TL, Sanders AB, et al. A prospective observational study of medication errors in a tertiary care emergency department. Ann Emerg Med. 2010;55:522-526.

4. The Eight Rights: Errors @ UWMC ED • Start (or stop) medication • Right Patient • Right Route • Right Drug • Right Dose • Right Time • Right Documentation • Right to Refuse • Right Response

5. Right Route: Epinephrine Intramuscular Intravenous Pulseless cardiac arrest 1mg IV Push 10 mL of a 1:10,000 solution • Anaphylaxis: • 0.3 mg IM • 0.3 mL of a 1:1000 solution

6. Epinephrine • New Policy Approved at UWMC • For Acute Allergic Reaction: • Route should always be IM • Dose should always be 0.3mg • Concentration should always be 1mg/mL

7. Right Drug: Immediate vs. Timed Release • Immediate release: • Drug absorption not delayed beyond original pharmacokinetic profile • Immediate release (IR)

8. Right Drug: Immediate vs. Timed Release • Timed release • Prolong absorption: Longer dosing intervals & less drug level fluctuation • Sustained-release (SR) • Sustained-action (SA) • Extended-release (ER, XR, XL) • Timed-release (TR) • Controlled-release (CR) • Modified release (MR) • Continuous-release (Contin)

9. Right Drug: Immediate vs. Timed Release • Opioids • Oxycodone (IR, CR) • Morphine (IR, ER) • Cardiovascular • Metoprolol (IR, XL) • Diltiazem (IR, CD) • Antidepressants • Bupropion (IR, SR, XL) • Venlafaxine (IR, XR)

10. Right Drug: Immediate vs. Timed Release

11. Right Drug: Sound Alike Medications • Metoclopramide vs. Metoprolol • Benadryl vs. Benazapril • Clonazepam vs. Clonidine • Methadone vs. Mephyton • Dobutamine vs. Dopamine

12. Right dose: Sedation & Vasoactive Drips • Drip rate errors • Vasoactive drips • Epinephrine • mcg/kg/min • Norepinephrine • mcg/kg/min • Phenylephrine • mcg/kg/min • Dopamine • mcg/kg/min • Dobutamine • mcg/kg/min • Sedation • Propofol • mcg/kg/min

13. Right dose: Sedation & Vasoactive Drips • Why so confusing? • Units not universally standard • New providers • Drug information resources • mcg/kg/min vs. mcg/min

14. Right dose: Sedation & Vasoactive Drips ICU Drug information Sheets Starting doses Titration schedules Drug administration pearls Monitoring parameters RED binders Rooms 1-5 Contain ICU drug information sheets Code carts Side of cart Drip mixing and dosing

15. Right dose: Sedation & Vasoactive Drips ICU Drug information Sheets Starting doses Titration schedules Drug administration pearls Monitoring parameters RED binders Rooms 1-5 Contain ICU drug information sheets Code carts Side of cart Drip mixing and dosing

16. Right dose: Sedation & Vasoactive Drips ICU Drug information Sheets Starting doses Titration schedules Drug administration pearls Monitoring parameters RED binders Rooms 1-5 Contain ICU drug information sheets Code carts Side of cart Drip mixing and dosing

17. Right dose: Sedation & Vasoactive Drips ICU Drug information Sheets Starting doses Titration schedules Drug administration pearls Monitoring parameters RED binders Rooms 1-5 Contain ICU drug information sheets Code carts Side of cart Drip mixing and dosing

18. Right dose: Sedation & Vasoactive Drips ICU Drug information Sheets Starting doses Titration schedules Drug administration pearls Monitoring parameters RED binders Rooms 1-5 Contain ICU drug information sheets Code carts Side of cart Drip mixing and dosing

19. Right Dose: Heparin • Multiple Concentrations: • 1 unit/mL • 10 unit/mL • 1,000 units/mL • 5,000 units/mL • Various infusions • Various rates • Various Targets

20. Right Time: Prostacyclin Infusions • Life-sustaining continuous infusions: • Treprostinil (Remodulin) • Epoprostenol (Flolan) http://www.muschealth.com/ph/education/medications.htm

21. Prostacyclin Policies • For Patients who present with prostacyclin infusions: • !!!DO NOT INTERRUPT PROSTACYCLIN INFUSION!!! • !!!DO NOT INTERRUPT PROSTACYCLIN INFUSION!!! • !!!DO NOT INTERRUPT PROSTACYCLIN INFUSION!!!

22. Prostacyclin Policies • Inform ED Pharmacist of all patients requiring prostacyclin infusion • If no ED Pharmacist, inform inpatient pharmacy • Blood cultures from prostacyclin infusion line need to follow Prostacyclin Infusion Policy

23. Prostacyclin Policies • Resources for infusion management or infusion complications: • Stephanie Harrie Nolley, Pulmonary Vascular Nurse Coordinator • STAT nurses • Pharmacists

24. Prostacyclin PoliciesOn UWMC Intranet, “Policies and Procedures”

25. Prostacyclin PoliciesUnder Patient Care Services, “Nursing Policies and Procedures”

26. Prostacyclin Policies

27. Questions

28. Sepsis + Antibiotics • Sepsis: every minute counts… • Start antibiotics immediately, but which one? And more than one?

29. Sepsis + Antibiotics

30. Sepsis + Antibiotics

31. Questions