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What’s New in the
Patient Safety World
December 2022
Rapid Response Team
Activations and Medication-Related Events
Despite a considerable literature on rapid response teams, we’ve yet to see a comprehensive analysis of the underlying reasons for such activations. Of course, a variety of physiological parameters are what lead to such activations, but we are talking about the underlying causes of those physiological phenomena.
A new study from Australia (Levkovich 2022) found that medication-related events led to a substantial proportion of Medical Emergency Team (MET) activations. The study was conducted at two academic teaching hospitals in Melbourne, Australia that had mature Rapid Response Systems. Over a 3-week study period, they found 628 MET activations. Of these, 23.2% were medication related: an incidence of 15.5 medication-related MET activation per 1000 admissions. Medication-related MET activations occurred a median of 46.6 hours earlier in an admission than non-medication-related activations, and this group also had more repeat MET activations during their admission.
Most importantly, 63% of medication-related MET activations were felt to be potentially preventable. Some specific examples were:
· tachycardia due to omission of beta-blocking agents (10.9%)
· hypotension due to cumulative toxicity (9.8%) or inappropriate use (10.9%) of antihypertensives.
Over half (55.5%) of the medication-related MET activations were related to medication errors and cardiovascular medications were most often involved. Omissions of cardiovascular medications were the most common error. But inappropriate use of cardiovascular medications was also common. Such adverse drug reactions were often dose-related (18.5%) or time-related (17.8%). Beta blockers and antihypertensives were the medications most often implicated.
The accompanying editorial (Härkänen 2022) expressed surprise that more typical high-alert medications, such as anticoagulants and opioids were not commonly involved in MET activations in this study. The authors suggest might be because those serious ADE’s
are managed differently (eg. with antidotes) before there is a need for a MET. Another potential reason is that cardiovascular medications can cause rapid hemodynamic changes resulting in a MET/RRT activation, whereas anticoagulant and opiate errors typically do not. A third reason might be that cardiac arrest cases were excluded from the sample.
The editorialists suggest that the high number of events related to omission of cardiovascular medications might be related to either ineffective medication reconciliation on admission or to long waits in the emergency department or boarding of patients admitted to the emergency department.
The Levkovich study is an important contribution to our understanding of unexpected clinical deterioration of patients in the hospital. Hospitals could probably benefit from common cause analysis (see our October 2020 What's New in the Patient Safety World column “Common Cause Analysis”) of their RCA’s (root cause analyses) on rapid response team activations.
Our other columns on rapid response teams:
- August 2007 “Responding to Patients with Clinical Deterioration”
- November 27, 2007 “More on Rapid Response Teams”
- August 2008 “AHRQ's New Patient Safety Primers”
- December 2008 “Rapid Response Teams Don’t Live Up to Expectations”.
- April 2009 “Early Emergency Team Calls Reduce Serious Adverse Events”
- December 29, 2009 “Recognizing Deteriorating Patients”.
- February 2010 “Rapid Response Teams Still Not Cutting
It”
- November 11, 2014 “Early Detection of Clinical
Deterioration”
- April 28, 2015 “Failure to Escalate”
- February 2017 “BOGO
Applies to Adverse Events, Too”
- May 26, 2020 “Early Warning Scores”
- December 1, 2020 “An Early Warning System
and Response System That Work”
- July 13, 2021 “The Skinny on Rapid
Response Teams”
References:
Levkovich BJ, Orosz J, Bingham G, et al. Medication-related Medical Emergency Team activations: a case review study of frequency and preventability. BMJ Quality & Safety 2022; Published Online First: 05 July 2022
https://qualitysafety.bmj.com/content/early/2022/07/05/bmjqs-2021-014185
Härkänen M, Syyrilä T, Schepel L. Adverse drug events leading to medical emergency team activation in hospitals: what can we learn? BMJ Quality & Safety 2022; Published Online First: 21 November 2022
https://qualitysafety.bmj.com/content/early/2022/11/20/bmjqs-2022-015275?rss=1
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