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 1 Patanwala 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% 1 Patanwala 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: Start (or stop) medication – Right Patient – Right Route – Right Drug – Right Dose – Right Time – Right Documentation – Right to Refuse – Right Response Errors @ UWMC ED

5. Right Route: Epinephrine Intramuscular Anaphylaxis: – 0.3 mg IM – 0.3 mL of a 1:1000 solution Intravenous Pulseless cardiac arrest – 1mg IV Push – 10 mL of a 1:10,000 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 DrugPeakPyxis Oxycodone (immediate)1-2 hoursYES Oxycodone CR or OxyContin4-5 hoursNO Morphine IR1 hourNO Morphine ER or MSContin4 hoursYES

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!!!

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 Policies On UWMC Intranet, “Policies and Procedures”

25. Prostacyclin Policies Under 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 Tobramycin, Gentamicin, Metronidazole, Bactrim, ampicillin IF multiple antibiotics ordered, check compatibility OR give afterwards: Ciprofloxacin, Levofloxacin, Moxifloxacin, Vancomycin Antibiotics that should be Given FIRST Meropenem, Aztreonam, Ceftriaxone, Cefepime, Ceftazidime, Penicillin G, Piperacillin/Tazobactam

30. Sepsis + Antibiotics

31. Questions