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August 23, 2016
ISMP Canada: Automation Bias and Automation Complacency
“It must be right, the computer said so.” Unfortunately, that concept has become very ingrained into our thinking and we see more and more adverse events related to over-reliance on technology. We love technology and think it is one of the most important tools in our armamentarium to help prevent medical errors and adverse patient outcomes. Yet we end up every year writing several columns on the unintended consequences of technology (see the list of those columns at the end of today’s column).
This month, ISMP Canada published a safety bulletin on over-reliance on technology (ISMP Canada 2016). They first described a patient incident and then focused on two very important and related concepts: automation bias and automation complacency.
The incident occurred in a patient admitted with new onset seizures. An order for phenytoin was handwritten using the brand name Dilantin. A hospital pharmacy staff member, who was relatively new to the clinical area, entered the first 3 letters “DIL” into the pharmacy IT system. The staff member was then interrupted and, when the task was resumed, diltiazem 300 mg was ordered instead of Dilantin 300 mg. Back on the clinical unit the handwritten order had correctly been transcribed by a nurse into the MAR. Later, when another nurse obtained the evening’s medications for the patient from the ADC (automated dispensing cabinet), he/she noted a discrepancy between the MAR and the ADC display but accepted the information on the ADC display as being correct. The diltiazem was erroneously administered and the patient developed significant hypotension and bradycardia.
Another example of over-reliance on technology that we give in several of our presentations is a near-miss involving insulin. A physician, from a specialty not used to ordering insulin, did medication reconciliation and mistook the “U-100” formulation of insulin listed on records accompanying the patient to be a dose of 100 units of insulin. The physician entered a dose of 100 units of regular insulin into the CPOE system. The pharmacy system did not have dose range limits for insulin and there was no prompt for special review by the pharmacist. The nurse who received the syringe with 100 units of regular insulin was somewhat surprised by the relatively high dose but barcoded the patient’s wrist band ID and the medication and looked at the electronic MAR, all of which indicated correct patient, correct medication, correct dose. So the medication was administered. Fortunately, because the nurse had an “uneasy feeling” she went back and checked the patient’s records and found that he had been on 10 units of regular insulin prior to admission. She drew a stat blood glucose level and administered D50W and potentially serious harm was prevented. In the old days, of course, a nurse would have immediately checked the records and the orders and spoken to the ordering physician before administering such a high dose of insulin. But, here, our tendency to believe that the technology is always correct biased the nurse toward first administering the insulin then checking further rather than checking further before administering it.
The first type of error in the ISMP Canada example is one we have encountered since the very first computers came out: the cursor error (also known variously as the mouseclick error, drop-down list error, picklist error, stylus error, or juxtaposition error depending upon the setting and device being used). We’ve all done it – you have a list of choices and you think you touched one choice yet your cursor or stylus actually hit the choice above or below the one you wanted. Usually we look to see what was chosen but, as in the ISMP Canada example, we may get distracted and not notice our erroneous choice (Yes, your email might get sent to someone you didn’t want it to go to!).
But the gist of the ISMP Canada article is not the error of choosing the wrong medication from a drop-down list. Rather, it is about our tendency to over-rely on technology and assume the technology is correct. They discuss two interrelated concepts: automation bias and automation complacency. Automation bias is “the tendency to favor or give greater credence to information derived from an automated decision-making system…and to ignore a manual (non-automated) source of information that provides contradictory information”. Examples are accepting the information on the ADC display rather than the handwritten MAR in the ISMP Canada example, or the acceptance of the barcoding system rather than the “gut feeling” in our insulin example. The closely related “automation complacency” refers to “monitoring of an automated process less frequently or with less vigilance than optimal because of a low degree of suspicion of error and a strong belief in the accuracy of the technology”. Both ignore the fact that the technology is only as good as the data that gets input.
ISMP Canada notes 3 factors contribute to automation bias and automation complacency: (1) our tendency to select the pathway with the least cognitive effort, (2) our perception that the analytic capability of automated aids is superior to humans, and (3) we often “shed” our responsibility when an automated system is performing the same function.
(Note that similar factors may contribute to the complacency we often see in double check systems as we’ve described in our October 16, 2012 Patient Safety Tip of the Week “What is the Evidence on Double Checks?”.)
The ISMP Canada article goes on to discuss the conflicting evidence as to the effect training and experience might have on automation bias and automation complacency. Some studies suggest that inexperience predisposes to such errors whereas other studies suggest increased familiarity with a technology may lead to desensitization and habituation.
ISMP Canada recommends training about automated systems both at orientation and on an ongoing basis, including discussion of limitations of such systems and any gaps or previous errors identified. It also suggests allowing trainees to experience automation failures during training. Further, a proactive risk assessment (eg. FMEA or failure mode and effects analysis) or a staged implementation should be used with new technologies to help identify unanticipated vulnerabilities. Input from end-users should be sought up front and feedback should be sought after implementation. They also have recommendations about avoiding interruptions during double checks, having standardized ways to address identified medication discrepancies, and the importance of comparing the ADC display with the MAR when selecting a medication from the ADC.
Note that there are other issues in the ISMP Canada incident that are important. One is failure to include an indication for the drug being ordered. A good system (whether manual or computerized) should require an indication. That gives everyone the opportunity to say “wait a minute, diltiazem is not used for treating seizures”. (But keep in mind that the indication may not be known for many medications taken prior to admission and continued during hospitalization.)
And the insulin example illustrates problematic medication reconciliation and lack of manual and electronic review of dosages for a high alert medication. One excellent patient safety intervention for high-risk drugs is setting dose range limits on your CPOE or pharmacy IT systems. This is very valuable in preventing, for example, overdoses of chemotherapy agents. For insulin, it is much more difficult than it sounds. That is because the dosages of insulin used are so variable across patients. Particularly at a large hospital treating lots of complex patients it might not be surprising for a nurse to have administered 100 units of insulin to a patient. But it is still worth looking at your data and saying “we’ve seldom used a dose of insulin exceeding x units” and then adding an alert that helps physicians, pharmacists or nurses question orders for large doses of insulin.
In aviation safety a term often encountered is “automation surprise”. That refers to the fact that many complex computerized aviation systems may have the aircraft flying in a mode that is relatively masked to the pilot. For example, an aircraft may be flying under autopilot and if the autopilot disengages the pilot may not immediately be aware of several important flight parameters. There are numerous instances in the NTSB files about automation surprises contributing to aviation crashes. You, yourself, may have experienced an “automation surprise” when your motor vehicle sped up as you were approaching the rear of another vehicle because you forgot your car was on cruise control.
Reports to NASA’s Aviation Safety Reporting System also provide examples of how attention to autoflight can lead to loss of situational awareness (NASA 2013). In examples, awareness of the aircraft’s actual flight path seems to have been compromised by:
In our January 7, 2014 Patient Safety Tip of the Week “Lessons From the Asiana Flight 214 Crash” we noted that one of the major issues contributing to this crash was apparently overreliance on technology. The pilots apparently thought that the automatic throttle system was engaged, which should have increased engine thrust when the airplane speed fell below the recommended speed. However, that automatic throttle system was not engaged. Once the pilots recognized that their speed and altitude were too low and that the autothrottle had not automatically increased speed, they tried to initiate a “go round” (i.e. to abort the landing and fly around and try again) but it was too late. It’s pretty clear that sometimes pilots don’t understand what mode the computer systems are in. The FAA released a comprehensive study on the overreliance of pilots on automation and loss of situational awareness due to automation surprises (FAA 2013).
Healthcare is no different. We often use computer systems in which multiple “modes” are available and we may not recognize which mode the system is operating in. Also, in all our discussions about alarm issues we note that erroneous assumptions are often made that an alarm will trigger when anything serious happens.
The bottom line: we all likely have some degree of automation bias and automation complacency in both healthcare and our other daily activities. We still need to use common sense and never assume that the technology is flawless. In our June 2, 2009 Patient Safety Tip of the Week “Why Hospitals Should Fly…John Nance Nails It!” we noted that we all should really look at each thing we are doing in patient care and think “could what I am about to do harm this patient?”.
See some of our other Patient Safety Tip of the Week columns dealing with unintended consequences of technology and other healthcare IT issues:
ISMP Canada. Understanding Human Over-reliance on Technology. ISMP Canada Safety Bulletin 2016; 16(5): 1-4
NASA. Autoflight Associated Loss of Situational Awareness. Callback 2013; 407: 1-2 December 2013
FAA. Operational Use of Flight Path Management Systems. FAA September 5, 2013
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Our March 15, 2016 Patient Safety Tip of the Week “Dental Patient Safety” noted numerous cases of death related to sedation in dental practices. The majority of those cases occurred in pediatric patients. A recent article in Anesthesiology News (Kronemyer 2016) noted that a KVUE TV “Defenders” investigation (Pierrotti 2016) identified at least 85 patients in Texas who died shortly following dental procedures from 2010 to 2015. The Kronemyer article also notes that the American Dental Association (ADA) guidelines on sedation do not specifically address pediatric dental issues and that statewide regulations regarding dental sedation and anesthesia vary widely. That article notes that the ADA defers to the American Academy of Pediatrics (AAP)/American Academy of Pediatric Dentistry (AAPD) “Guideline for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures.” Fortunately, the latter guideline has just been updated (Coté 2016).
The updated guideline, which applies to not just dental procedures but to sedation for all procedures, notes that children under the age of 6 years (and especially those under the age of 6 months) are particularly likely to suffer adverse events during sedation. It emphasizes that there is a very narrow margin in children between the intended level of sedation and much deeper sedation or anesthesia. Therefore, the practitioner must be trained not only in moderate sedation but must have the skills to rescue patients from such deeper levels. That would include the need for maintenance of the skills needed to rescue a child with apnea, laryngospasm, and/or airway obstruction, include the ability to open the airway, suction secretions, provide continuous positive airway pressure (CPAP), perform successful bag-valve-mask ventilation, insert an oral airway, a nasopharyngeal airway, or a laryngeal mask airway (LMA), and, rarely, perform tracheal intubation. The guidelines note these skills are likely best maintained with frequent simulation and team training for the management of rare events. The guideline has specific recommendations for when the intended level of sedation is minimal, moderate, deep or general sedation.
The updated guideline emphasizes the role of capnography in appropriate physiologic monitoring and continuous observation by personnel not directly involved with the procedure to facilitate accurate and rapid diagnosis of complications and initiation of appropriate rescue interventions. You’ll recall from our March 15, 2016 Patient Safety Tip of the Week “Dental Patient Safety” that many of the fatalities following sedation for dental procedures had the dentist or oral surgeon both doing the procedure and monitoring the patient.
Patient safety considerations for procedural sedation begin in advance of the procedure. There should be a careful preprocedure review of the patient’s underlying medical conditions and consideration of how the sedation process might affect or be affected by such conditions. The guideline specifically mentions that children with developmental
disabilities have been shown to have a threefold increased incidence of desaturation compared with children without developmental disabilities.
The SOAPME mnemonic is used to help teams remember all the equipment and supplies needed for conduct of safe sedation:
O Oxygen; an adequate reserve supply
A Airway; size-appropriate equipment to manage a nonbreathing child
P Pharmacy; drugs needed to support life and appropriate reversal agents
M Monitors; size-appropriate oximeter probes/monitors appropriate for procedure
E Equipment; a defibrillator with appropriately sized pads
Without going into details about specific drugs, the guideline notes the importance of selecting the lowest dose of drug with the highest therapeutic index for the procedure. That choice should also depend on whether the procedure is expected to be a painful or non-painful procedure. Knowledge about the duration of action of the drugs is important in informing how long a patient needs to be monitored after the procedure. That is especially important when combinations of drugs are being used (eg. a sedating agent and an analgesic or anxiolytic agent).
The guideline has specific recommendations for when the intended level of sedation is minimal, moderate, deep or general sedation. One critical point that should be of particular concern for dental practices, is that use of moderate or deeper sedation shall include the provision of a person, in addition to the practitioner, whose responsibility is to monitor appropriate physiologic parameters and to assist in any supportive or resuscitation measures. While that individual might also be responsible for assisting with interruptible patient-related tasks of short duration, such as holding an instrument or troubleshooting equipment, the primary role of that individual is monitoring the patient. For deep sedation the sole role of the support individual is to monitor the patient. In either case that individual should be trained in and capable of providing advanced airway skills (eg, PALS) and shall have specific assignments in the event of an emergency and current knowledge of the emergency cart/kit inventory.
Monitoring is critical and should include the level of patient’s ability to communicate (where assessable), heart rate, respiratory rate, blood pressure, oxygen saturation, and expired carbon dioxide values (via capnography) should be recorded, at minimum, every 10 minutes in a time-based record. The guideline stresses use of capnography but acknowledges that it may not be able to be used in some procedures around the face, including many dental procedures.
The guideline discusses the needs for the emergency cart/kit and backup emergency services access and availability.
The guideline has a good discussion about the use of immobilization devices, such as the “papoose” boards we mentioned in our March 15, 2016 Patient Safety Tip of the Week “Dental Patient Safety”. Such must be applied in such a way as to avoid airway obstruction or chest restriction and the child’s head position and respiratory excursions should be checked frequently to ensure airway patency. If an immobilization device is used, a hand or foot should be kept exposed, and the child should never be left unattended.
The guideline discusses what should be documented before, during, and after a procedure in which sedation is used and notes the importance of careful attention to calculating doses of drugs or infusions based on patient weight.
The guideline has a good discussion about discharge of the pediatric patient following a procedure in which sedation is used. It specifically highlights the dangers when a child is transported in a car seat where there is a need to carefully observe the child’s head position to avoid airway obstruction. Transportation in a car safety seat poses a particular risk for infants who have received medications known to have a long half-life. When there is only one adult to both drive and observe the child, there should be a longer period of observation in the facility where the procedure occurred. Discharge instructions should include details about what to look for, activity levels, dietary restrictions, and include a 24-hour phone number to call if necessary.
And while we have been emphasizing the application of the guideline to dental procedures, remember it applies to all diagnostic and therapeutic procedures. It has an excellent section on sedation in the MRI suite, which is a very restricted environment and has needs for special equipment and monitoring techniques as we have discussed in our numerous columns on patient safety issues in the radiology and MRI suites.
This guideline was extremely well researched, with almost 500 references including the most up-to-date studies and reports. The authors have produced very valuable recommendations that should improve the safety of children undergoing sedation for procedures in a variety of settings. You’ll find this very useful.
Kronemyer B. Deaths of Children During Dental Procedures Raise Safety Concerns. Anesthesiology News 2016; June 30, 2016
Pierrotti A. Defenders: Investigating Dental Deaths. KVUE 2016; April 28, 2016
Coté CJ, Wilson S, American Academy of Pediatrics, American Academy of Pediatric Dentistry. Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016. Pediatrics 2016; 138(1): e2016121
Last month we discussed new guidelines on antibiotic stewardship (see our July 2016 What's New in the Patient Safety World column “NQF/CDC Guideline on Antibiotic Stewardship”) and in our several other prior columns on antibiotic stewardship listed below we’ve noted the overprescription of antibiotics for inappropriate indications, both in hospitals and ambulatory settings.
One such category where inappropriate antibiotic prescribing is rampant is the upper respiratory tract infection (RTI) that is usually self-limited and many of which are caused by viruses so are not amenable to antibiotic treatment. Many primary care practitioners remain concerned that failure to use antibiotics in such cases may lead to adverse consequences in their patients. They often have the impression that the primary reason for avoiding antibiotic prescribing is to prevent development of antibiotic-resistant organisms and that such concern applies to populations rather than to their individual patients. In fact, that’s not true as we discussed in our November 2015 What's New in the Patient Safety World column “Medications Most Likely to Harm the Elderly Are…” that the medications most likely to harm the elderly are antibiotics.
But it would be reassuring to see a study showing that avoidance of antibiotics in such cases is, in fact, safe. So a recent study done in 601 general practices in the UK provides such welcome reassurance. Researchers used data from the UK Clinical Practice Research Datalink (Gulliford 2016). They found that general practices that adopt a policy to reduce antibiotic prescribing for RTIs might expect a slight increase in the incidence of treatable pneumonia and peritonsillar abscess. However, there was no increase likely in mastoiditis, empyema, bacterial meningitis, intracranial abscess, or Lemierre’s syndrome.
They estimate that if a general practice with an average list size of 7000 patients reduces the proportion of RTI consultations with antibiotics prescribed by 10%, then it might observe 1.1 more cases of pneumonia each year and 0.9 more cases of peritonsillar abscess each decade. They conclude that even a substantial reduction in antibiotic prescribing was predicted to be associated with only a small increase in numbers of cases observed overall, but caution might be required in subgroups at higher risk of pneumonia.
An accompanying editorial (Del Mar 2016) also finds some reassurance in these findings. Some rapid response letters (Rapid Response 2016) note the importance of adequate early followup and cooperation of parents when treating pediatric patients. But another of the rapid response letters reveals a critical root cause of overprescribing antibiotics – the already harried general practitioner fears his workday will become overburdened by patients returning for an additional evaluation.
In our July 2016 What's New in the Patient Safety World column “NQF/CDC Guideline on Antibiotic Stewardship”) we noted that CMS has announced that hospitals will be required to have antibiotic stewardship programs and demonstrate that they have reduced inappropriate antibiotic usage (CMS 2016). Now The Joint Commission has also revised its standard regarding antibiotic stewardship, effective January 1, 2017 (TJC, 2016).
Elements of the new TJC standard for include:
As a reminder, the seven CDC-defined core elements (CDC 2016) of a comprehensive antibiotic stewardship program are:
The TJC prebulication document also provides links to some useful tools, such as materials for educating patients and their families
See our columns listed below for ways to deal with the problem of inappropriate antibiotic prescribing and antibiotic stewardship programs both in the hospital and the ambulatory setting.
Some of our prior columns on antibiotic stewardship:
Gulliford MC, Moore MV, Little P, et al. Safety of reduced antibiotic prescribing for self limiting respiratory tract infections in primary care: cohort study using electronic health records. BMJ 2016; 354: i3410 (Published 04 July 2016)
Del Mar C. Antibiotics for acute respiratory tract infections in primary care. BMJ 2016; 354: i3482 (Published 05 July 2016)
Rapid Responses. Antibiotics for acute respiratory tract infections in primary care. BMJ 2016; 354: i3482 (Published 05 July 2016)
CMS (Centers for Medicare & Medicaid Services). CMS Issues Proposed Rule that Prohibits Discrimination, Reduces Hospital-Acquired Conditions, and Promotes Antibiotic Stewardship in Hospitals. June 13, 2016
TJC (The Joint Commission). New Antimicrobial Stewardship Standard (Prepublication Requirements). June 24, 2016
CDC (Centers for Disease Control and Prevention). Core Elements of Hospital Antibiotic Stewardship Programs. Page last updated: May 25, 2016
Two recent studies suggest that hand hygiene compliance rates are overestimated when healthcare workers know they are being observed. The first, a California medical center study presented at the 43rd Annual Conference of the Association for Professionals in Infection Control and Epidemiology (APIC), found a difference of more than 30 percent in hand hygiene compliance depending on whether or not they recognized the auditors (APIC 2016a). The Hawthorne effect, very loosely applied to imply that behavior changes when subjects know they are being observed (our apologies to purists who will state that is not the actual phenomenon observed at Western Electric), appears to result in an overestimate of compliance with hand hygiene.
The second study, done in Canada, also showed a disparity between healthcare worker compliance with hand hygiene observed covertly compared to reporting by staff observers (Kovacs-Litman 2016). Moreover, there may be a disparity in the phenomenon between physicians and nurses. Canadian researchers trained students to covertly observe hand hygiene compliance and compared their assessments with the formal compliance assessments done by hospital staff. The covert observers noted hand hygiene compliance to be 50% compared to 83.7% reported by the hospital staff. For physicians compliance reported by hospital auditors and covert observers, respectively, was 73.2% vs 54.2%, whereas for nurses compliance reported by hospital auditors and covert observers, respectively, was 85.8% vs 45.1%.
Importantly, as we’ve often pointed out, the behavior of the head of the team significantly influences the behavior of all the others. The researchers noted that physician trainees had much better hand hygiene compliance when their attendings cleaned their hands than when they did not (79.5% vs. 18.9%).
Meanwhile, many hospitals have begun to use electronic monitoring of hand hygiene compliance even though this technology has not yet been shown to substantially reduce hospital infections. But a new study (Kelly 2016), analyzing data from 23 inpatient units over a 33-month period found a significant correlation between unit-specific improvements in electronic monitoring compliance and reductions in methicillin-resistant Staphylococcus aureus infection rates.
Another study presented at the recent APIC Annual Conference found that showing hospital staff enlarged images of bacterial cultures similar to those they might have on their hands increased compliance with hand hygiene by 11-46% (APIC 2016b).
Of course, the attending physician serving as a role model for hand hygiene and the use of visual imagery to promote hand hygiene are forms of “nudges” (see our July 7, 2009 Patient Safety Tip of the Week “Nudge: Small Changes, Big Impacts”). In our April 2016 What's New in the Patient Safety World column “Nudge: An Example for Hand Hygiene” we cited an article that showed location of hand sanitizers significantly influenced their use by visitors (Hobbs 2016). The key finding was that when the hand sanitizers were placed in the middle of the lobby (with limited landmarks or barriers) visitors were 5.28 times more likely to use them.
So how about locating hand sanitizers right on healthcare workers? Researchers at Darthmouth-Hitchcock Medical Center and UMass Memorial Medical Center did just that (Koff 2016). They randomly assigned operating room environments to usual intraoperative hand hygiene or to a personalized, body-worn hand hygiene system. They found an 8-fold increase in anesthesia and circulating nurse provider hand decontamination events above that of conventional wall-mounted devices. However, use of the hand hygiene system was not associated with a reduction in healthcare-associated infections.
Improving hand hygiene compliance rates remains a frustratingly difficult endeavor in most healthcare facilities. But we can all learn from successes elsewhere. Every little bit helps.
Some of our other columns on handwashing and hand hygiene:
January 5, 2010 “How’s Your Hand Hygiene?”
December 28, 2010 “HAI’s: Looking In All The Wrong Places”
May 24, 2011 “Hand Hygiene Resources”
October 2011 “Another Unintended Consequence of Hand Hygiene Device?”
March 2012 “Smile…You’re on Candid Camera”
August 2012 “Anesthesiology and Surgical Infections”
October 2013 “HAI’s: Costs, WHO Hand Hygiene, etc.”
November 18, 2014 “Handwashing Fades at End of Shift, ?Smartwatch to the Rescue”
January 20, 2015 “He Didn’t Wash His Hands After What!”
September 2015 “APIC’s New Guide to Hand Hygiene Programs”
November 2015 “Hand Hygiene: Paradoxical Solution?”
April 2016 “Nudge: An Example for Hand Hygiene”
APIC (Association for Professionals in Infection Control and Epidemiology). The Hawthorne Effect hinders accurate hand hygiene observation, study says. APIC News Release 2016; June 10, 2016
Kovacs-Litman A, Wong K, Shojania KG, et al. Do physicians clean their hands? Insights from a covert observational study. J Hosp Med 2016; Early View 5 July 2016
APIC (Association for Professionals in Infection Control and Epidemiology). Seeing is believing: Visual triggers increase hand hygiene compliance. APIC News Release 2016; June 9, 2016
Hobbs MA, Robinson S, Neyens DM, Steed C. Visitor characteristics and alcohol-based hand sanitizer dispenser locations at the hospital entrance: Effect on visitor use rates.
Am J Infection Contol 2016; 44(3): 258-262
Koff MD, Brown JR, Marshall EJ, et al. Frequency of Hand Decontamination of Intraoperative Providers and Reduction of Postoperative Healthcare-Associated Infections: A Randomized Clinical Trial of a Novel Hand Hygiene System. Infect Control Hosp Epidemiol 2016; 1-8 Published onlne June 7, 2016
Kelly JW, Blackhurst D, McAtee W, Steed C. Electronic hand hygiene monitoring as a tool for reducing health care–associated methicillin-resistant Staphylococcus aureus infection. Am J Infect Control 2016; Published online: June 23, 2016
We’ve done several columns (listed below) on the dangers of home infusion therapy for cancer chemotherapy agents. In most cases the dangers have arisen when an agent intended to be infused over several days is instead infused over several hours, leading to toxicity and, in some cases, death.
But cancer chemotherapy is not the only type of home infusion therapy that may be dangerous. ISMP Canada (ISMP Canada 2016) recently did a column about a fatal case related to intravenous vancomycin therapy in the home but their excellent recommendations apply to almost any type of home infusion therapy.
The case described was a diabetic patient with a foot ulcer who was receiving IV vancomycin at home after a hospital stay. Recommended bloodwork, including trough vancomycin levels, was not done due to a faulty lab requisition. The patient developed a rash, thrombocytopenia, and high serum vancomycin levels as well as rising creatinine. He was rehospitalized but despite IV fluids and platelet transfusions, he developed hypertensive episodes, epistaxis and mental status changes and developed intracerebral bleeding and ultimately died. The acute kidney injury was attributed to vancomycin toxicity and the thrombocytopenia was also felt possibly related to the vancomycin.
ISMP Canada makes recommendations that are appropriate not only for home vancomycin infusions but also for any drug requiring therapeutic drug monitoring. Good planning prior to discharge is critical. The prescriber should decide whether an oral agent or an intravenous agent not requiring therapeutic drug monitoring might be an alternative therapy. The team should determine whether all the treatment and monitoring needs can, in fact, be met with homecare (as opposed to followup in a hospital ambulatory setting or continued inpatient admission). They should liaise with the most responsible health care provider who will be responsible for ongoing monitoring and assessment of the patient in the community prior to the patient’s discharge. Copies of any laboratory requisitions and any special instructions should be provided. Prescriptions and completed laboratory requisitions should be provided and they recommend avoiding Friday bloodwork since results may be delayed over weekends or holidays. Particularly important with potentially nephrotoxic drugs like vancomycin is a review and possible adjustment of any concomitant medications that might promote nephrotoxicity. The latest bloodwork should be reviewed before administering each dose of the drug. In addition to discussing the care plans with the home health agencies and/or community pharmacists, it is important that the patient or family be educated on the importance of getting the bloodwork done and what signs or symptoms should raise concerns. Hospital pharmacists familiar with the therapeutic drug monitoring should be part of the discharge team and may serve as the liaison with community pharmacists where appropriate.
The article also has a link to ISMP Canada’s transitions toolkit and checklist, a very valuable resource for facilitating safe discharge of patients.
But what happens at home is not the only problem with home infusion. ISMP (US) notes that home infusion therapies may also give rise to problems when such patients are admitted to hospitals or emergency departments (ISMP 2015). ISMP notes that patient safety can be jeopardized if the devices are mishandled when filling, programming, attaching, and monitoring the pumps and that the ambulatory pump marketplace is diverse, so the devices rarely have standard components. Therefore, serious errors can occur when healthcare providers are not familiar with these ambulatory pumps. The classic problematic one is the insulin pump, as we’ve described in several columns, because the vast majority of healthcare workers are not familiar with its use. Healthcare workers may not know whether the pump is functioning properly nor how to get replacement parts or batteries. There have also been cases where a physician orders and a nurse gives a dose of insulin after a patient has administered a dose without telling them. Every hospital should have a team headed by an endocrinologist who can manage insulin pumps in the hospital. That may be a challenge for rural hospitals, though use of telemedicine may help.
Our prior columns related to chemotherapy safety:
Some of our prior columns on medication errors in other ambulatory settings:
June 12, 2007 “Medication-Related Issues in Ambulatory Surgery”
August 14, 2007 “More Medication-Related Issues in Ambulatory Surgery”
March 24, 2009 “Medication Errors in the OR”
October 16, 2007 “Radiology as a Site at High-Risk for Medication Errors”
January 15, 2008 “Managing Dangerous Medications in the Elderly”
April 2010 “Medication Incidents Related to Cancer Chemotherapy”
September 2010 “Beers List and CPOE”
October 19, 2010 “Optimizing Medications in the Elderly”
April 12, 2011 “Medication Issues in the Ambulatory Setting”
June 2012 “Parents' Math Ability Matters”
May 7, 2013 “Drug Errors in the Home”
May 5, 2015 “Errors with Oral Oncology Drugs”
September 15, 2015 “Another Possible Good Use of a Checklist”
February 2016 “Avoiding Methotrexate Errors”
April 19, 2016 “Independent Double Checks and Oral Chemotherapy”
June 21, 2016 “Methotrexate Errors in Australia”
ISMP Canada. Gaps in Transition: Management of Intravenous Vancomycin Therapy in the Home and Community Settings. ISMP Canada Safety Bulletin 2016; 16(4): 1-5 June 28, 2016
ISMP Canada. Hospital to Home - Facilitating Medication Safety at Transitions. A Toolkit and Checklist for Healthcare Providers.
ISMP (Institute for Safe Medication Practices). Ambulatory pump safety: Managing home infusion patients admitted to the ED and hospital. ISMP Medication Safety Alert! Acute Care Edition 2015; September 10, 2015
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