This month’s supplement to the journal Critical Care Medicine is a theme issue about adverse events in the intensive care envrironment and has some really excellent patient safety articles.
One paper (Stockwell 2010) describes the various systems and sources of information that can be used for surveillance for adverse events in the ICU setting. These include not only the more historical methods that facilitate trending data over time but also some of the more real-time tools (like trigger tools) that may help lead to immediate interventions that may prevent such adverse events. They stress good systems utilize multiple methods for surveillance and detection. They also stress that you need a system of “just culture” in the ICU to facilitate your quality improvement efforts.
An excellent paper (Kane-Gill et al 2010) describes the risk factors for adverse drug events in the ICU. ICU patients are particularly vulnerable to adverse drug events because of the complexity of the ICU environment, multiple distractions, high risk of the individual patients, rapid changes in pharmacotherapy, complex drug regimens, frequent use of high alert medications, and the modes of medication administration. They discuss the economic impact of such adverse events, with each one costing $6000 to $9000. And they stress the role of the entire ICU team in the prevention of adverse events.
The paper on human factors in medication and patient safety in the ICU (Scanlon 2010) is excellent and provides a comprehensive review of the research done in human factors engineering and understanding a systems approach to medical care. And the article on nursing implications (George 2010) further describes many of the important human factors involved in the ICU.
There is an outstanding article on the common drug interactions leading to adverse events in the ICU (Papadopoulos 2010). Going well beyond the usual discussion of renal and hepatic influences on drugs in ICU patients, this paper discusses effects of gastric pH and gastric motility, disruption of intestinal flora, changes in protein binding, chelators, various cytochrome systems, disease state interactions, coagulopathies, infection, and drug-laboratory interactions among others.
Not surprisingly, given our previous series of articles on delirium and issues of ICU oversedation, our favorite article in this supplement is the one on adverse events associated with use of analgesics, sedatives and antipsychotics in the ICU (Devlin 2010). This article provides excellent discussions about both oversedation in the ICU and delirium and also discusses some of the more unusual problems encountered with specific drugs, such as muscle rigidity with Fentanyl and propofol-related hypertonicity and seizure-like movements, It has a good description of drugs causing hypotension, hypertension, bradycardia, tachycardia, prolongation of the QTc interval, and arrhythmias. It even has a section on the toxicities of some of the other substances in IV formuations, such as propylene glycol, and a thorough discussion of the propofol-related infusion syndrome. And, importantly, it stresses the complications of withdrawal from a variety of agents used.
And, of course, no theme issue on adverse drug events in the ICU would be complete without a paper on using technology to prevent such events (Hassan 2010). This paper is incredibly thoughtful and presents a very balanced view of both the potential benefits of each technology but also the unintended consequences and the complexities of implementation. Among the technologies discussed are automated dispensing devices, robotics dispensing systems, bar-code medication administration systems, CPOE with clinical decision support, smart pump technology, tele-health technology, and a variety of other useful tools.
And there are good articles on drug-induced arrhythmias and drug-related effects on coagulation, thrombocytopenia, renal, hepatic, endocrine, GI and electrolyte systems, antimicrobial resistance and hyperthermia. There’s even one on genetic predisposition to adverse drug events in the ICU.
Critical Care Medicine. June 2010 - Volume 38 - Supplement, Identification and Prevention of Common Adverse Drug Events in the Intensive Care Unit
Stockwell, David C.; Kane-Gill, Sandra L. Developing a patient safety surveillance system to identify adverse events in the intensive care unit. Critical Care Medicine. 38():S117-S125, June 2010
Kane-Gill, Sandra L.; Jacobi, Judith; Rothschild, Jeffrey M.
Adverse drug events in intensive care units: Risk factors, impact, and the role of team care. Critical Care Medicine. 38():S83-S89, June 2010.
Scanlon, Matthew C.; Karsh, Ben-Tzion. Value of human factors to medication and patient safety in the intensive care unit. Critical Care Medicine. 38():S90-S96, June 2010
George, Elisabeth L.; Henneman, Elizabeth A.; Tasota, Frederick J. Nursing implications for prevention of adverse drug events in the intensive care unit. Critical Care Medicine. 38():S136-S144, June 2010
Papadopoulos, John; Smithburger, Pamela L. Common drug interactions leading to adverse drug events in the intensive care unit: Management and pharmacokinetic considerations. Critical Care Medicine. 38():S126-S135, June 2010
Devlin, John W.; Mallow-Corbett, Stephanie; Riker, Richard R. Adverse drug events associated with the use of analgesics, sedatives, and antipsychotics in the intensive care unit. Critical Care Medicine. 38():S231-S243, June 2010
Hassan, Erkan; Badawi, Omar; Weber, Robert J.; Cohen, Henry. Using technology to prevent adverse drug events in the intensive care unit. Critical Care Medicine. 38():S97-S105, June 2010