Drugs- Don't Stop Til You get Enough?
EM physicians deliver drugs many times a day.......... but most have a common lexicon of drugs they use, if not every day, certainly every week. These familiar drugs are just that, familiar. We know their indications, contraindications, mixing agents, routes and rates of delivery.
Outside that comfortable ball park things can be more challenging. That's fine, we all have a huge variety of resources to turn to. Here in the UK the bible is the British National Formulary which tells you everything you ever wanted to know (and probably quite a lot you didn't) about any medicine available in the UK.
Medicines Complete is a great resource which may even be free in your NHS hospital.. and that really does have more information than even the most zealous pharmacist in the country could ever want.
But what happens in an 'emergency'. The patient's pulse may be up a bit. They may be looking a little pale and sweaty. Your pulse is up a bit. You may be looking a little pale and sweaty. But hold on- you do know whats going on and you do know what to do. This patient needs drug X... and they need it now.
Here's a couple of cases where a 'stop moment' might have helped (see the end of this article)
Route Cause Analysis
A 60 something year old lady was being treated for
possible encephalitis. Shortly after administration of cefotaxime and whilst
the aciclovir was still running she complained of shortness of breath and lip
swelling. A diagnosis of anaphylaxis was
made and a verbal instruction for 1:1,000 adrenaline, 500 mcg was made by the
treating doctor. No route was specified. The drug was drawn up and the
aciclovir disconnected. The adrenaline was then given, but in error the
intravenous route was used.
The patient had a brief period of hypertension
and some short runs of VT over the next few minutes before settling apparently
without further issue. She did not suffer any chest pain but did raise a troponin.
Good Care
An immediate apology was given, and an
investigation launched including a duty of candour letter being sent.
What Went Wrong
The staff member who gave the IV dose in error
knows perfectly well that adrenaline should be given IM in anaphylaxis. However
she was distracted by disconnecting the IV acyclovir which she did immediately
prior to picking up the adrenaline syringe.
The drug prescription was not written but given
as a verbal instruction, this meant a route check was not made against the
script.
There was also an atmosphere of anxiety at the
time due to the perceived urgency of the situation
Learning Bites
This is a classic ‘human errors’ mistake. The staff were anxious, a little rushed, a
little bit distracted and were doing something they rarely do- a potent ‘cock-up’cocktail.
There are very few occasions that a drug
truly cannot be written up before it is given- allowing a check to occur.
If
you are about to deliver a drug or perform a procedure that you do rarely- make
yourself pause- ‘right patient, right procedure,right site’-
It’s your own stop moment of safety Resuscitation Council UK- Anaphylaxis Guidance
Trivial Trivia- Take your Pick
Adrenaline - the name given to a purified extract of adrenal
glands by Jokichi Takamine in 1901 - it’s Latin for ‘above the kidneys’
Epinepherine - the name given to a purified
extract of adrenal glands by John Abel in 1897 - it’s Greek for ‘above the
kidneys’
What’s in a Name- Check Me?
A man in his 40s became
unwell on the ward. He was noted to be increasingly confused with a fast
irregular heart rate of about 140. An ECG showed fast Atrial Fibrillation. He
had never had documented AF before. He was discussed with the cardiology on call
team who recommend use of an intravenous beta blocker, metoprolol. The doctor
wrote the prescription up. Two nurses then checked the prescription and drew up
the drug together. The syringe was passed to the doctor in an IV tray with the
drug vial, for him to provide a third check. He read the drug bottle and
administered the drug.
Shortly afterwards the
patients’ blood pressure was noted to be very high. The doctor was surprised at
this expecting the opposite effect. He rechecked the drug vial and found that
he had actually administered a dose of metaraminol. Metaraminol is a drug used
to raise blood pressure in patients’ undergoing anaesthesia. It has a brief
period of action. Following discussion with ITU, the patient’s blood pressure
was left to normalise before metoprolol was given for the AF.
Good Care
As soon as the patient did
not respond in the manner the doctor expected he re-checked what he had given.
The error was therefore spotted quickly.
A full apology was given a
datix completed and staff appropriately supported
Learning Bites
Intravenous medicines must
always be independently checked by a second person accredited to administer
intravenous medicines
This ‘second check’ must be
performed independently. Practitioners should be aware that the process of
checking can be adversely influenced by the following factors:
-Deference to a more senior or experienced
colleague
-Presuming the other person
has performed the process in a correct, accurate and thorough manner
-Repeating the words and
actions with the first person
-Diminished sense of
responsibility or complacency in the second checker.
-Lack of time and/or
hurrying
In this case all three
individuals were senior…it is likely they all falsely reassured each other-
STOP. CHECK. BE INDEPENDENT
Learning from Other Specialties- 'The Stop Moment'
What's that got to do with me in my EM practice I hear you cry?
Well- when was the last time you inserted a chest drain- what checks did you do before putting pointy object to skin?
Do you perform fascia-illiaca blocks for NoF anlagesia? (if you don't- you should watch this- St Emlyn's )
The anesthetists recognised several common features in their series of errors, just tell me if any of these sound familiar ;
NHS England has recognised theses issues are transferable and have produced some useful guidance. This is contained within the REALLY IMPORTANT National Safety Standards for Invasive Procedures (NatSSIPs)
However A 'Stop Moment' need not apply to surgical procedures/blocks alone.
It just as easily applies to drug delivery, blood transfusion, prescribing.... especially when you are at your most vulnerable to error- stressed, pressured, tired, glycopaenic or working with the unfamiliar.
I mean, when would any of that ever happen in an ED?
So try it- try and introduce a stop moment to your practice-
Just before you give a drug.
Just before you site a needle .
Just before you place a knife to skin.
STOP- Right Patient? Right Procedure? Right Site? Right Way
