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A medical malpractice case of a middle-aged woman hospitalized for a nearly-deadly allergic reaction to seafood and being administered the correct treatment in the wrong manner bolsters federal government efforts to promote proper prescription drug use and disposal with the kickoff of American Pharmacists Month and such public sector and nonprofit campaigns as the National Prescription Drug TakeBack Day.

Around January 2012, a 40-year-old woman was brought into an emergency room of a Washington, D.C. hospital for a severe allergic reaction to seafood but ended up suffering a near-heart attack resulting from the misadministration of the hormone and neurotransmitter adrenalin, also known as epinephrine,which is meant to treat heart attacks.

The woman was hospitalized with shortness of breath and a rash. She also had edema of her throat — namely, inflammation and water accumulation — while making harsh, high-pitched breathing sounds (stridor).

Emergency room physicians reported her body temperature at 98.7 degrees Fahrenheit, which is one degree higher than normal (98.6 degrees F). She registered a blood pressure reading of 100/69 mm Hg (millimeters of mercury), which was slightly below the recommended 120/80 norm. Her pulse was normal at 70 bpm (beats per minute) as the healthy adult range for the heart rate spans between 60 to 100 bpm.

The patient was provided with a supply of oxygen and the medical team ordered a 0.5 mg (milligrams) dose of epinephrine. After intravenous infusions of the epinephrine dosage, the woman “complained of chest pains on her left side with tingling in her fingertips”.

A electrocardiography (ECG) reading reflected increases in sinus tachycardia (ST) in her and levels of her serum creatine kinase, all of which indicate a heart attack.
Over the next 10 minutes, she was provided with two dosages of 0.4 sublingual nitroglycerin, a member of a class of nitrate drugs typically used by physicians to prevent chest pain (angina) in a patient, especially one with coronary artery disease.

The woman suffered chest pains because her heart muscle did not receive enough blood. Nitroglycerin works by relaxing and widening blood vessels to enable blood to flow more easily to the heart. The procedure, which was meant to return her heart rate and blood pressure to normal levels, succeeded.

When other doctors investigated her condition and its treatment, it was found that, while the correct drug and dosage — 0.5 mg of epinephrine — was ordered, the manner of administration was not specified and the woman incorrectly received the drug intravenously rather than intramuscularly for anaphylaxis.

In medical lexicon, anaphylaxis is defined as “a serious allergic reaction that is rapid in onset and may cause death. It typically causes a number of symptoms, including an itchy rash, throat swelling and low blood pressure. Common causes include insect bites/stings, foods and medications.

The woman’s near-death treatment case was an example of a medical error but highlights the importance of proper drug use, especially the correct method of administration. As with all medical errors, prescription drug misadministration are caused by the failed completion of an action or the wrong process that may end in injury or death of a patient.

Federal researchers say such medical errors cause injury in one out of 25 hospital patients and results in more deaths than car accidents, breast cancer or AIDS from person to person. Such medical errors lead to $2.4 million extra hospital days and higher health costs of nearly $17 to $29 billion a year.

Such errors occur in different areas of the health care system, including medication, diagnostic and surgical mistakes and may involve pharmacists, physicians, physician assistants, nurse practitioners and nurses. Other factors are included such as communication errors and equipment failure and can have an impact on the incidence and seriousness of the mistake.

Researchers add that nearly 25 percent of all drug-related injuries may be prevented. Of the four billion prescriptions filled annually, over 50 million mistakes are related to these drugs. Drug-related mistakes can take place anywhere within the prescription process from unintelligible physician handwriting to inaccurate transcription and improper administration.

Common causes connected with drug medication are classed according to the nature of the mistake. Under “miscommunication of prescriptions” falls the errors of “illegible handwriting, inappropriate abbreviations, look-a-like or sound-alike drug names such as ephedrine or epinephrine, leading and trailing zeroes and incomplete orders”.

Oftentimes, mistakes are made due to a lack of information about the drug or the patient. Dosing miscalculations fall under the “dispensing errors” category. Finally, there are administration and transcription errors and a failure to follow correct procedure, which can include not double-checking if the correct drug is being administered with the right dosage, route, time or patient.  

In particular, epinephrine, the adrenalin hormone and neurotransmitter, is used to treat heart, vascular and other smooth muscles in the human body and is indicated for anaphylaxis and heart attack. The drug is available in different concentrations and doses and is administered in varying routes, depending on the condition of the patient and need.

Several factors come into play to increase the risk of a mistake in dosing and proper administration. One example is its availability in various concentrations. Physicians, nurses and pharmacists are asked to be mindful of the different concentrations, what they mean and which are appropriate for specific conditions. They must all take into account the possibility of misreading their concentrations because of the number of zeros used.

Many heart attacks and anaphylactic reactions are treated in the emergency room which heightens the risk of a misreading of labels and concentrations of epinephrine and other such drugs.
Additionally, overdoses occur with miscommunication among healthcare professionals, a lack of knowledge of proper dosing and miscalculation of doses.

While the medical industry attempts to resolve this problem with such strategies as the use of pre-filled syringes, which can help reduce the confusion about epinephrine and its various concentrations, they may lead to more problems.

For instance, the concentrations of injectable epinephrine may be supplied with a measurement of their mass (i.e., mg or mg/mL) as opposed to ratios (i.e., 1:1,000) that most healthcare professionals are used to.

Such differences may not be appreciated in an emergency room setting. For example, a medical cart wheeled into a room could hold two different pre-filled syringes, one for intramuscular administration and another for intravenous administration at different concentrations, making an occasion for a mistake.
The federal agency Agency for Healthcare Research and Quality (ARHQ) created a list of “never events,” which identifies incidents within health care that “should never happen.”
Included are drug mistakes that should never lead to death or disability.

Hospitals and medical facilities nationwide are using computers and information technology in general to improve their odds of avoiding mistakes in medical practice and drug administration. They are using computerized physician order entry technology (CPOE) to check for drug interactions, allergies, multiple doses or incorrect drug orders and can help reduce repetition and mistakes.

They are also using clinical decision support systems (CDSS), which are software to link patients to a computerized database to create a patient-specific diagnosis or care plan.
One role of the CDSS is to send computerized reminders to hospital staff to ensure that standard policy is followed.

Additionally, hospitals and medical facilities are using an electronic bar code system and records to reduce drug mistakes.
Computers and technology aside, healthcare professionals are urged to remain aware of their own actions and any mistakes that may arise. Research finds that participation of pharmacists in clinical rounds cuts back on drug errors by 78 percent. Drug mistakes can take place at any point in the prescription process but they can be prevented or decreased if all members of the healthcare system play their part.

(NOTE: In honor of American Pharmacists Month, PharmPsych.com is offering up articles and advice columns on various subjects concerning the work of pharmacists, the field of pharmacy and those who support both. Vladimire Herard is chief communications officer for PharmPsych.com, our medical communications company and online community portal, and its sister websites, and freelancing contributing writer.)

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Last updated October 2014