Transcript Why Poisoned Kids Are Not Just Little Adults

Medication Safety:
The Role of Poison centers
G. Randall Bond, MD
Medical Director
Cincinnati Drug and Poison Information Center
Cincinnati Children’s Hospital Medical Center
Professor
Clinical Pediatrics and Emergency Medicine
University of Cincinnati School of Medicine
To Err is Human
Institute of Medicine estimated that 44,000
to 98,000 people die annually due to
medical errors and that medication-related
errors represent one of the most common
types of errors in hospitalized patients.
To Err is Human. Institute of Medicine 1999
Medication Safety
Are medications safe for use?
Rare but serious ADE
Are medications used safely?
“Medication errors”
Medication Safety
Past = “error”
Wrong Drug
Wrong Dose
Wrong Patient
Wrong Route
Individual focused
Practitioner focused
Knowledge focused
Blame focused
Problem: individual error
Solution:
Know more
Be more careful
But …improvement science suggests:
In a human process,
carefulness can only reduce
error rate to 1%-10%.
So with a 4 step process,
each with 5% error risk…
0.95 x 0.95 x 0.95 x 0.95= 0.81
Likelihood of error is 19%
1 in 5 patients?
A simple multi-step process
Medication Safety
Future = “safety system failure”
System/process focused
Shared responsibility
Multi-party empowered
Prevention focused
Drug choice--condition and
patient factors
Drug ordering and
communication
Drug preparation
Drug delivery to caregiver
Communication about how
Drug delivery into patient
Role for Poison centers?
Poison centers as agent to reduce
pediatric medication related injuries
Classic poison center function.
How are we doing?
AAPCC data (age < 6 years):
1990
2.2 ped. pharm. exp. per 1000 pop. served
7.9 ped. pharm. deaths per 100 M pop. served
2006
1.8 ped. pharm. exp. per 1000 pop. served
7.0 ped. pharm. deaths per 100 M pop. served
From www.aapcc.org
Impact seems minimal decrease in both, but is it
impact of poison centers’ prevention effort or …
Impact of altered reporting patterns?
Shift from iron to opioid deaths in children!
“indirect reports” included?
Aggressive discovery of deaths by PC
Already max. benefit of previous PC impact?
Already max. benefit of previous societal
prevention acts?
Changes in the medications available?
Safety packaging and dispensing?
Limited OTC quantities?
Impact of non-drugs?
Role of improved ICU care?
Poison centers as agents to
understand the process
Understanding the process: PCs as
source of detailed root cause analysis
Some reports.
Few at NACCT or EAPCCT
Understanding the process: using pooled
PC medication misuse & injury data
All US NPDC data queried:
Age < 5 years
2000-2004
Therapeutic error or misuse
Outcome—severe injury or death
Look for agents and cause
Tzimenatos et al. #
238 severe injuries or death
162 exposure occurred in the home*
70 exposure occurred in health care facilities*
107 (45%) < 1 year of age
171 due to excessive dosing
# Submitted, unpublished
*Error may have occurred elsewhere
Specific issues
Anticonvulsants
25 low margin, levels rose
Fosphenytoin
6 all 10 fold errors
Cough and cold meds 18 parental excess
Acetaminophen 27 parent confusion, misdose, combo
Local anesthetics 11 excess dosing by physicians
Metoclopramide 18 small volume non-standard suspension
Methylergonovine 7 all as neonate got mothers med
Clonidine
7 …two 1000 fold errors
What makes a medication higher risk
for patient injury?
Basic toxicity (low therapeutic/toxic margin)
Variable dosing (pediatrics)
Med is unfamiliar to prescriber, dispenser or
user (e.g., antidotes)
Toxicity only in special circumstances (renal
failure, neonate, interaction, genetics)
Subject to imprecise communication (phone,
handwritten)
What makes a medication higher
risk for patient injury?
Dose/Volume confusion risk (variable
concentration, small pt. size)
Use in high stress environment (e.g., code)
User misperception of risk (“intentional”
dosing errors—physician, nurse, parent, self)
High risk for mistake—name (look alike sound
alike), size or color (tablet or container)
Use in multi-med and multi patient environment (L
& D)
Administration (oral or aerosol dose by
syringe/pump in IV environment)
Poison center inquiry for ADE reports?
ADE or interaction could be the reason for
symptoms initiating the call…
Every call is an opportunity to learn--Sentinel
events, even near miss event (double dose,
wrong med taken). Why? How?
Planned investigation– e.g., OTC meds
Poison center inquiry for ADE reports?
Database inquiry--exposures calls not suicide,
therapeutic error, misuse, … by medication for
symptom complaint pattern
PC data is pooled, spontaneous, need-driven,
public inquiry,—not dependent on a single
physician making the connection.
Unusual ADEs
e.g., suicidal thoughts
SSRI, montelukast have been linked
Drug specific OD rate ( / 1000 calls) / sales
with some adjustment for indication and
severity
* Caution OD report may not reflect
baseline meds and may be biased
toward antidepressants
Poison centers as supplemental
educator/risk assessor
US call for a national agenda to reduce
medication error includes…
“Paradigm shift in the patient provider
relationship…patients to take a more active
role in their own healthcare…communicate
more…improve quality and accessibility of
information about medications provided to
consumers …internet…”
Preventing Medication Errors. IOM report 2006
Poison centers as supplemental
educator/risk assessor
Cincinnati Drug and Poison Info Center
served 5 million population in 2007
45,000 “exposure” calls including hospital
6,000 medication inquiries from physicians
10,000 medication inquiries from public
170,000 “pill ID calls”
of which 97,000 involved abusable drugs
USA—65 PCs, 300 million pop.
Potentially 1,000,000 medication inquiries at
current DPIC levels
More if developed as a resource and funded!
Poison centers as harm reduction agent?
Cincinnati Drug and Poison Info Center
served 5 million population in 2007
45,000 “exposure” calls including hospital
6,000 medication inquiries from physicians
10,000 medication inquiries from public
170,000 “pill ID calls”
of which 97,000 involved abusable drugs
Poison centers as harm reduction agent?
The new Erowid or Dance-Safe in the age or
prescription drug abuse—info as a harm
reduction tool?
We tried it—97,000 times last year
Unclear that it reduced harm (they likely
take it anyway). No follow up. No data.
No one to support it (Funding?)
What can European poison centers do
that US poison centers can’t?
Different legal system means more willingness to
share adverse events for help
Greater access to physician reports
Generally more complete reports
Link to public health authority allows access to
hospital charts and more “invasive” data
gathering
Integrated public health systems allow better
assessment of medication
use/impact/interaction/genetics
Toxbase, etc. and internet issues
Online resources are cheap, but limit case
related data collection.
How many times do physicians use
databases to see if symptoms are known
side effects?
Brief question or problem description as the
“price” for access?
Poison center as a contributor to
medication error
Wrong answer
Solution: data availability & use
Poor communication
Solution: inclusion standards & summary
Miscommunication
Solution: Conflict resolution for clarity
Look alike sound alike
Solution: spell or read back & describe
Mis-entry of conversation
Solution read back, fax?
Poison Centers are here to help