1. Solutions for Confusion Adam Sutherland Clinical Pharmacist, PICU, RMCH Clinical Lecturer, University of Manchester

3. Patient A 6/12 Septic, hypotensive. Undiagnosed complex condition GDD GORD Congenital hyperinsulinaemia …and the rest! Monday 0630 Hypotensive 35/40 Lactate 5 pH 6.91 0640 Loss of output CPR commenced 3 x adrenaline Rx. adrenaline infusion 0.1microgram/kg/min A LIFE IN THE DAY…

4. 0700 CPR ongoing Adrenaline infusion commenced 0710 No response to adrenaline. Dose increased to 2microgram/kg/min Request to remake infusion 0715 Day nurse and night nurse make infusion together: Day nurse finds adrenaline ampoules 1:10,000 in tray A LIFE IN THE DAY… TRANSCRIPT Day (D) “What volume of 1:10,000 did you draw up for that infusion?” Night (N) “Just what it said on the calculator” D “Just that volume?” N “Yeah!” D “They’re different strengths…” N “No they’re not; they’re the same. They’re both adrenaline” D “No! This is ten times weaker than what’s on the chart…”

5. ROOT CAUSES 1) Human error in wrong concentration selection 2) Service failure in training 3)20 minutes to commence infusion CONTRIBUTING FACTORS Nursing preparation at the bedside Rule-of-Six A LIFE IN THE DAY…

6. 6mg/kg of drug X in 100ml of Diluent Y Rate = 1ml/hr Dose = 1microgram/kg/min THE RULE OF SIX 1980 vintage infusion pump 2014 infusion pump

7. THE RULE OF SIX STRENGTHS 1.Quick calculations at the bedside (?) 2.Embedded into unit practice 3.Predictable fluid load –But still too much…? 4.Simple to titrate –As long as you know what the concentration is in the syringe…

8. WEAKNESSES 1.Complex prescribing 2.Complex calculations for dilution and preparation 3.Relies on impossibly accurate measurement and dilution 4.Slow to deliver from point of ordering THE RULE OF SIX

9. To debunk the Rule of Six To present potential benefits of standardisation –Patient care –Patient safety –Unit efficiency WHY AM I HERE?

10. The rule of six CAUSES medication error –Prescribing –Calculation –Dilution –Administration Errors are common, undetectable and CANNOT be overcome –Parshuram 2003-Opiate infusions in PICU –Wheeler 2007-Inotropes in Adult ICU –Allegaert 2011-Paracetamol in NICU –Aguado-Lorenzo 2013-Opiate infusions in NICU Not negligent, just human DEBUNKING THE RULE OF SIX

11. Ped Crit Care Med 2006; 7(3); 225

12. Parshuram C et al. Ped Crit Care Med 2003 31(10);2483 Causes of inaccuracy Human eye measurements Inadequate mixing Use of concentrated solutions DEBUNKING THE RULE OF SIX

13. Parshuram et al. CMAJ 2008; 178(1);42 CMAJ 2008; 178(1): 2

14. DEBUNKING THE RULE OF SIX Arch Dis Child 2013:98; 975

15. DEBUNKING THE RULE OF SIX

16. What are the implications: Patient instability at infusion change Slow response to new orders Patient response Nursing preparation Is ongoing instability related to: Real instability of the patient OR Because the infusion is the wrong strength

17. DEBUNKING THE RULE OF SIX Recommendations for IV infusion safety Standardisation (Roman 2005) Ready mixed ready to use containers (NPSA 2007) Longer running infusions (Apkon 2004) Electronic prescribing Pre-programmed syringe drivers (maybe: Murdoch 2008 ) Roman, N. (2005). Dimensions of Critical Care Nursing, 24(6), 275–278. Apkon, M. (2004). Quality and Safety in Health Care, 13(4), 265–271. Murdoch, L (2008)British Journal of Nursing, 17(10), 630–6.

18. DEBUNKING THE RULE OF SIX Fluid load… Paediatr child Health 2008 13(5):371

19. DEBUNKING THE RULE OF SIX REGULATORY ACTION

20. DEBUNKING THE RULE OF SIX REGULATORY ACTION Risk assessment Ready to use solutions Reducing ward-level manipulation 74 incidents in TWO years; 4 “serious harm”; 2 “death” “Consider pre-filled syringes”

21. DEBUNKING THE RULE OF SIX Borthwick et al. 2007; JICS 8(1): 92

22. DEBUNKING THE RULE OF SIX IF WE DON’T EFFECT CHANGE OURSELVES ON OUR TERMS SOMEONE ELSE WILL FORCE US TO DO IT ON THEIRS