What’s New in the Patient Safety World
April 2010
Medication Issues in the Emergency Department
We do a lot of patient safety initiatives on medication safety. However, one area that often is overlooked on medication safety is the emergency department. Perhaps that is because fewer drugs are ordered or prescribed there than in most other settings. Yet the ED is extremely important in terms of continuity of care. Medication reconciliation typically starts in the ED. And the ED must convey back to the next practitioner any additions or changes made in the patient’s medications.
Two recent papers address medication issues in the ED. The first documented that ED crowding is associated with an increased frequency of medication errors (Kulstad et al 2010). This was a prospective observational study in a large community emergency department. They performed a sampling of patients seen in the ED and identified various medication errors. They then evaluated frequency of those errors against the Emergency Department Work Index (EDWIN) score. Not surprisingly, there was a positive correlation between medication error frequency and the daily EDWIN score. Errors ran the gamut of medication errors and included medication name confusion, wrong route, incorrect dosing, and others. They discuss various predisposing factors that occur in most ED’s such as high volume, high acuity, clinical uncertainty, multiple handoffs, and staff shortages. To that we would add that in many ED’s the health information technology systems have not been integrated with the rest of the hospital IT systems.
The second paper looked at prescribing of potentially inappropriate medications (from Beer’s List) to older adults in the ED (Meurer et al 2010). Using a large national ambulatory database, they determined that 16.8% of ED visits were associated with prescription or administration of at least one potentially inappropriate medication to elderly adults. The five most commonly prescribed PIM’s were promethazine, ketorolac, propoxyphene, meperidine and diphenhydramine. There was a correlation between PIM’s and total number of medications prescribed or administered. There was also a higher frequency in rural locations outside the Northeast and being seen by a staff physician only (as opposed to a resident or intern).
Our January 15, 2008 Patient Safety Tip of the Week “Managing Dangerous Medications in the Elderly “ focused on prescribing of medications on Beer’s List that may be potentially inappropriate in the elderly, as did our June 2008 What’s New in the Patient Safety World column “Potentially Inappropriate Medication Use in Elderly Hospitalized Patients”. Many hospitals and ambulatory settings have integrated CPOE alerts for drugs on Beer’s List. Unfortunately, many or even most ED’s do not currently use CPOE for ordering medications.
References:
Kulstad EB, Sikka R, Sweis RT, Kelley KM, Rzechula KH. ED overcrowding is associated with an increased frequency of medication errors. American Journal of Emergency Medicine 2010; 28: 304-309
http://www.ajemjournal.com/article/S0735-6757%2808%2900831-0/abstract
Meurer WJ, Potti TA, Kerber KA, Sasson C, et al. Potentially Inappropriate Medication Utilization in the Emergency Department Visits by Older Adults: Analysis From a Nationally Representative Sample.
Academic Emergency Medicine 2010; 17: 231–237
http://www3.interscience.wiley.com/cgi-bin/fulltext/123305845/PDFSTART?CRETRY=1&SRETRY=0
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