Clinical Communiqué Volume 3 Issue 4 December 2016
Download PDF: Clinical Communiqué December 2016 Edition
In this edition
Case #1 A TOXIC TIMELINE
Case #2 KNOWING WHERE THE END LIES
Case #3 TRUMPING AN ORDER
Expert Commentary A SLIP, A LAPSE AND THE ROLE OF HIERARCHY IN MEDICATION ERROR
Expert Commentary NFR CHALLENGES AND CHANGES
Welcome to the final issue for 2016. In this issue we look at three cases where medication errors contributed to the cause of death. There is extensive literature available on the types of medications errors, their prevalence, and the hard work that has been done so far to reduce this substantial cause of adverse events in healthcare settings. The Australian Commission on Safety and Quality in Healthcare identified the importance of improving the safety and quality of medication usage in Australia, and listed it as a National Safety and Quality Health Service Standard (NSQHS Standard 4).
All medicines can be toxic if given incorrectly, however, there are some routinely prescribed and administered medicines that if used in error, are more likely to cause catastrophic patient harm. These medications can be summarised by the acronym ‘A PINCH’: Antiinfective agents, Potassium, Insulin, Narcotics, Chemotherapeutic agents, Heparin and other anticoagulants. They generally have in common a narrow therapeutic window of action, and pose a serious potential problem when administered via the incorrect route, or in the setting of significant co-morbidities. The cases in this issue demonstrate frequently prescribed medications from three of the high risk categories listed in the acronym above.
Medication safety was the original concept for this issue. The cases soon revealed though, another equally important and related theme around the dilemmas of not-for-resuscitation (NFR) orders in the setting of medication misadventures. This led us to ask ourselves – why do such errors occur? And then, to consider further: should a pre-existing NFR order be overturned and a Code Blue be called when an iatrogenic event is suspected? under what circumstances would it be appropriate not to resuscitate a patient in the setting of an iatrogenic event? and, are there any specific steps or additional decisions and actions that should take place regarding resuscitation following an iatrogenic event?
We are very privileged to have two expert commentaries in this issue to tackle the questions raised. Dr Elizabeth Roughead provides an insightful analysis on slip-lapse and hierarchical errors, and Associate Professor Mark Boughey addresses the complex issues surrounding NFR orders. We also welcome back case précis authors, Dr Angela Sungaila, and Dr Sanjeev Gaya, from Clinical Forensic Medicine at the Victorian Institute of Forensic Medicine.
Finally, as we look forward to 2017, and reflect on the issues and cases that we have explored so far, we take this opportunity to acknowledge all the contributors to the Clinical Communiqué. Our sincerest thanks go to the busy clinicians who authored the case summaries and the expert commentaries, offering their valuable time and knowledge. It is due to their work, and their commitment to the impact of education to improve patient safety, that we have now published ten issues of the Clinical Communiqué with cases, themes and lessons that resonate with us all.