Medication Safety:The Role of Poison centers

G. Randall Bond, MDMedical Director

Cincinnati Drug and Poison Information CenterCincinnati Children’s Hospital Medical Center

ProfessorClinical Pediatrics and Emergency MedicineUniversity of Cincinnati School of Medicine

To Err is Human

Institute of Medicine estimated that 44,000 to 98,000 people die annually due to medical errors and that medication-related errors represent one of the most common types of errors in hospitalized patients.

To Err is Human. Institute of Medicine 1999

Medication Safety

Are medications safe for use?

Rare but serious ADE

Are medications used safely?

“Medication errors”

Medication Safety Past = “error”

Individual focused

Practitioner focused

Knowledge focused

Blame focused

Wrong Drug

Wrong Dose

Wrong Patient

Wrong Route

Problem: individual error

Solution:

Know more

Be more careful

But …improvement science suggests:

In a human process, carefulness can only reduce error rate to 1%-10%.

So with a 4 step process, each with 5% error risk…0.95 x 0.95 x 0.95 x 0.95= 0.81

Likelihood of error is 19%

1 in 5 patients?

A simple multi-step process

Medication SafetyFuture = “safety system failure”

System/process focused

Shared responsibility

Multi-party empowered

Prevention focused

Drug choice--condition and

patient factors

Drug ordering and

communication

Drug preparation

Drug delivery to caregiver

Communication about how

Drug delivery into patient

Role for Poison centers?

Poison centers as agent to reduce pediatric medication related injuries

Classic poison center function.

How are we doing?

AAPCC data (age < 6 years):

1990

2.2 ped. pharm. exp. per 1000 pop. served

7.9 ped. pharm. deaths per 100 M pop. served

2006

1.8 ped. pharm. exp. per 1000 pop. served

7.0 ped. pharm. deaths per 100 M pop. served

From www.aapcc.org

Impact seems minimal decrease in both, but is itimpact of poison centers’ prevention effort or …

Impact of altered reporting patterns?Shift from iron to opioid deaths in children!“indirect reports” included?Aggressive discovery of deaths by PC

Already max. benefit of previous PC impact?Already max. benefit of previous societal

prevention acts?Changes in the medications available?Safety packaging and dispensing?Limited OTC quantities?Impact of non-drugs?Role of improved ICU care?

Poison centers as agents to understand the process

Understanding the process: PCs as source of detailed root cause analysis

Some reports.

Few at NACCT or EAPCCT

Understanding the process: using pooled PC medication misuse & injury data

All US NPDC data queried:

Age < 5 years

2000-2004

Therapeutic error or misuse

Outcome—severe injury or death

Look for agents and cause

Tzimenatos et al. #

238 severe injuries or death

162 exposure occurred in the home*

70 exposure occurred in health care facilities*

107 (45%) < 1 year of age

171 due to excessive dosing

# Submitted, unpublished*Error may have occurred elsewhere

Specific issues

Anticonvulsants 25 low margin, levels rose

Fosphenytoin 6 all 10 fold errors

Cough and cold meds 18 parental excess

Acetaminophen 27 parent confusion, misdose, combo

Local anesthetics 11 excess dosing by physicians

Metoclopramide 18 small volume non-standard suspension

Methylergonovine 7 all as neonate got mothers med

Clonidine 7 …two 1000 fold errors

What makes a medication higher risk for patient injury?

Basic toxicity (low therapeutic/toxic margin)

Variable dosing (pediatrics)

Med is unfamiliar to prescriber, dispenser or user (e.g., antidotes)

Toxicity only in special circumstances (renal failure, neonate, interaction, genetics)

Subject to imprecise communication (phone, handwritten)

What makes a medication higher risk for patient injury?

Dose/Volume confusion risk (variable concentration, small pt. size)

Use in high stress environment (e.g., code)User misperception of risk (“intentional”

dosing errors—physician, nurse, parent, self)High risk for mistake—name (look alike sound

alike), size or color (tablet or container)Use in multi-med and multi patient environment (L

& D) Administration (oral or aerosol dose by

syringe/pump in IV environment)

Poison center inquiry for ADE reports?

ADE or interaction could be the reason for symptoms initiating the call…

Every call is an opportunity to learn--Sentinel events, even near miss event (double dose, wrong med taken). Why? How?

Planned investigation– e.g., OTC meds

Poison center inquiry for ADE reports?

Database inquiry--exposures calls not suicide, therapeutic error, misuse, … by medication for symptom complaint pattern

PC data is pooled, spontaneous, need-driven, public inquiry,—not dependent on a single physician making the connection.

Unusual ADEse.g., suicidal thoughts

SSRI, montelukast have been linked

Drug specific OD rate ( / 1000 calls) / sales with some adjustment for indication and severity

* Caution OD report may not reflect

baseline meds and may be biased

toward antidepressants

Poison centers as supplemental educator/risk assessor

US call for a national agenda to reduce medication error includes…

“Paradigm shift in the patient provider relationship…patients to take a more active role in their own healthcare…communicate more…improve quality and accessibility of information about medications provided to consumers …internet…”

Preventing Medication Errors. IOM report 2006

Poison centers as supplemental educator/risk assessor

Cincinnati Drug and Poison Info Centerserved 5 million population in 2007

45,000 “exposure” calls including hospital

6,000 medication inquiries from physicians

10,000 medication inquiries from public170,000 “pill ID calls”

of which 97,000 involved abusable drugs

USA—65 PCs, 300 million pop.

Potentially 1,000,000 medication inquiries at current DPIC levels

More if developed as a resource and funded!

Poison centers as harm reduction agent?

Cincinnati Drug and Poison Info Centerserved 5 million population in 2007

45,000 “exposure” calls including hospital

6,000 medication inquiries from physicians

10,000 medication inquiries from public

170,000 “pill ID calls”

of which 97,000 involved abusable drugs

Poison centers as harm reduction agent?

The new Erowid or Dance-Safe in the age or prescription drug abuse—info as a harm reduction tool?

We tried it—97,000 times last yearUnclear that it reduced harm (they likely take it anyway). No follow up. No data.

No one to support it (Funding?)

What can European poison centers do that US poison centers can’t?

Different legal system means more willingness to share adverse events for help

Greater access to physician reportsGenerally more complete reportsLink to public health authority allows access to

hospital charts and more “invasive” data gathering

Integrated public health systems allow better assessment of medication use/impact/interaction/genetics

Toxbase, etc. and internet issues

Online resources are cheap, but limit case related data collection.

How many times do physicians use databases to see if symptoms are known side effects?

Brief question or problem description as the “price” for access?

Poison center as a contributor to medication error

Wrong answer Solution: data availability & use

Poor communication Solution: inclusion standards & summary

Miscommunication Solution: Conflict resolution for clarity

Look alike sound alike Solution: spell or read back & describeMis-entry of conversation

Solution read back, fax?

Poison Centers are here to help