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What’s New in the
Patient Safety World
May 2020
PPSA on IV
Vancomycin Safety
Our August 2016 What's New in the Patient Safety World
column “Home
Infusion Therapy Pitfalls” highlighted a fatal case related to intravenous
vancomycin therapy in the home reported by ISMP Canada (ISMP Canada 2016).
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.
That’s the only case of a
vancomycin error we could find in our 14-year patient safety archive. But the
Pennsylvania Patient Safety Authority just published an extensive review of
safety hazards associated with intravenous vancomycin (Krukas
2020). The authors begin with the complexities of IV vancomycin use:
dosing is weight-based and management requires
monitoring of drug levels (peak and trough), attention to renal function, and
dosing at regularly scheduled intervals. They reviewed the literature and analyzed
cases involving vancomycin reported to the Pennsylvania Patient Safety
Reporting System (PA-PSRS).
Their literature review identified the following issues:
- Overdosing
- Underdosing
- Failure to adjust dose
based on trough levels or renal function
- Failure to monitor renal
function
- IV access issues
(infiltration, extravasation, need for PICC’s or other more advanced
access)
- Reactions to IV vancomycin
such as hypotension, chills, fever, and red man syndrome (RMS)
- Additive nephrotoxic
effects when combined with some other antibiotics or other nephrotoxic
medications
- Organizational barriers to
maintaining special dosing intervals
- Workflow issues
- Communication issues
They then analyzed 143 reports of event reported over a
3-month period related to IV vancomycin (they excluded many more reports if
there was no harm or just an unsafe condition that did not reach the patient).
Events occurred in multiple phases of the medication use
process: administration (38.5%), monitoring (27.3%), ordering/reviewing (19.6%).
The most frequent errors identified were dose omission/delay or receipt of partial
dose (41.3%), improper dose (29.4%), and monitoring errors (18.2%).
Workflow and communication issues often contributed to
missed doses, delays in doses, or suboptimal doses. Monitoring medication-use process
stage issues were mostly related to timing of troughs. Difficulties were especially
noted when doses and/or timing needed to be adjusted, including starting,
restarting, and stopping IV vancomycin.
Workflow and communication issues typically involved handoffs
and transfers, especially related to the ED and OR and transfer from these
units to other units. Order sets were sometimes confusing and in other cases paper
orders, faxed orders or verbal orders contributed.
Monitoring issues included lack of awareness that trough
levels were ordered but not drawn, results of trough levels not promptly
transmitted, or trough levels not acted upon.
They provide a terrific self-assessment
tool that any organization using vancomycin should download and use. They
stress the need to increase clinician awareness and developed an infographic
to help promote that. But, recognizing that education and training are of
limited value, they focus on potential interventions using health information
technology. They note studies showing that use of a weight-based vancomycin EHR
order set, specifically in ED settings,
resulted in a 20% increase in appropriate dosing (Hall
2015). Other interventions included automatic ordering of a trough level 30
minutes before the fourth dose when a new vancomycin order was placed, or an
alert in the nurse’s barcode administration of vancomycin if no trough level
had been drawn. One of our own recommendations would be to use clinical
decision support to generate an alert when a specified increase in serum
creatinine is seen after vancomycin is started.
This is a really good study that
has valuable lessons. Issues related to errors in IV vancomycin use probably
are underreported and “fly under the radar” in many healthcare organizations.
This study should be a wakeup call for all.
References:
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
https://www.ismp-canada.org/download/safetyBulletins/2016/ISMPCSB2016-04_Vancomycin.pdf
Krukas A, Franklin ES, Bonk C, et
al. Identifying Safety Hazards Associated With
Intravenous Vancomycin Through the Analysis of Patient Safety Event Reports. Patient
Safety 2020; 2(1): 17
https://patientsafetyj.com/index.php/patientsaf/article/view/vancomycin
PPSA (Pennsylvania Patient Safety Authority). IV Vancomycin
Safety Assessment Tool. PPSA 2020; March 2020
https://patientsafetyj.com/index.php/patientsaf/article/view/vancomycin/125
PPSA (Pennsylvania Patient Safety Authority). Vancomycin Inforgraphic. PPSA 2020; March 2020
https://patientsafetyj.com/index.php/patientsaf/article/view/vancomycin/127
Hall AB, Montero J, Cobian J,
Regan T. The Effects of an Electronic Order Set on Vancomycin Dosing in the ED.
Am J Emerg Med 2015; 33(1): 92-94
https://www.ajemjournal.com/article/S0735-6757(14)00704-9/fulltext
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What’s New in
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