A Pharmacist Mom’s Experience with the Health Care System

Allison Wells BSP, ACPRPAS Annual Conference

May 1, 2016

Presenter DisclosuresI have no current or past relationships with commercial entities

Learning ObjectivesBy the end of this presentation the pharmacy professional will:

Gain insight into the ups and downs of dealing with the medical system from the patient/family perspectiveReview an order that led to a critical medication error with a focus on the unique and important role we as pharmacists and technicians must play in the safe provision of drug therapy and patient careComtemplate how technology can improve patient safety Be prepared to Stop the Line the next time she sees a potential for patient harm

Show of HandsWho in the room is:

PharmacistTechnicianOther health care professionalCommunity basedHospital Based

Logan – Age 3

Our StoryRelatively uneventful pregnancy with nausea and vomiting until approximately 17 week, diet controlled gestational diabetes and some mild hypertension and edema requiring work restriction in last trimester. Logan was born August 15, 2010 weighing 8lbs 2 ozsConcerns raised at 2 week appt but dismissed as new-mom worryOver next 4 months: Failure to Thrive, breast- feeding

difficulties, feeding 150ml/kg/dayCloth diaperedBlood work on December 6 to ER

Our Story continuedLogan was feverish and vomiting throughout the nightRenal and Head Ultrasound normalTransferred to Saskatoon under Endocrinologist for DI workup after only 19 hours in Regina

Regina LabsLab Dec 6 @1925 Dec 7 @ 0117 Dec 7 @ 0740 Dec 7 @1205

Na (135-145) 165 167 171 170

K (3.5-5) 5.8 4.8 4.2 3.6

Cl (98-110) 130 135 137 139

CO2 (21-30) 21 22 28 27

Creatinine (60-130)

45 42 44 42

Urea (2-5.5) 7.4 5.9 4.8 3.9

Ca Cor (2.14-2.66)

2.73 2.74 2.71 2.62

Serum Osm (280-305)

339 351 356 349

Urine Osm (300-900)

127 136

Treatment NS 48ml thenD5 ½ NS @30ml/hr

NS 48ml then continue with same IV

Increase IV to 35ml/hr and start DDVAP 0.25mg IV. Replace urine + 15ml Q1H

Transfer to Saskatoon

Urine Urine lytesNa 41, K 12.1

u/o ~42ml/hr (8.7ml/kg/hr)

u/o 49ml/hr(10.1 ml/kg/hr)

u/o 75ml/hr(15.5ml/kg/hr)

Graphic created by Tim Weakland, father to NDI child

Saskatoon LabsDec 7 Dec 8 Dec 9 Dec

10Dec 11

Dec 12

Dec 13

Na 174 171 163 150 146 141 141K 2.8 4.9 5.1 5.0 5.0 4.1 3.7S Osm 332 333 311 309 296 295Fluids D5 ½

NS @ 2/3 1/3 with 20meq KCl/L

½ NS ½ NS 1/3 NS then locked

U/O 1769 ml(~14ml/kg/hr)

1734 ml(~14ml/kg/hr)

1357ml(~11 ml/kg/hr)

1211ml(~9.5ml/kg/hr)

801ml(~6ml/kg/hr)

634ml(~5ml/kg/hr)

539ml(~4ml/kg/hr)

Meds DDAVP 0.5 mcg SubQ

HCTZ 5mg po Daily (1 mg/kg/day)

HCTZ 5mg po BID (2mg/kg/day)

HCTZ 10mg po BID(4mg/kg/day)

Our Return HomeFeeding q1-2h Drinking 2 liters a dayVomiting, vomiting, vomitingNon-stop sleep deprivationNon-stop research and readingLOTS of email contact with our

nephrologist, dietitian and pharmacist

It’s the Little Things That Matter -

True Patient Centered Care

May 2014 Admission

The Day I Saved My Son’s Life…

or

…..the day our Health Care System tried to kill

my son

The Order

Na: 134, K 2.7 Age: 3.5 years old Weight: 11.9kg

Are we numb to potassium orders? Would you have caught

the errors?

What is the maximum recommended dose of potassium on a per kg basis in a 3.5 year old?What is the maximum recommended rate of potassium replacement in a 3.5 year old?What is the maximum recommended concentration to be administered peripherally?

Potassium ReviewDose

Usual dose is 0.5-1mEq/kg/dose. Logan’s was written as 1.7 meq/kg/dose.

RateUsual rate is 0.3mEq/kg/hr

“as ordered’ the rate should have been over 5.6 hours. This is a 5.6 times rate error

Maximum rate is 1mEq/kg/hr‘as ordered’ the rate could have gone as fast as 1.6 hours. This is a 1.6 times rate error.

If infusion rate exceeds 0.5 mEq/kg/hr the patient should have continuous ECG monitoring with physician at the bedside.

Reference : Lexicomp

Potassium ReviewPeripheral concentration

Logan received 40mEq/100ml solution Usual concentration 20 mEq/L.

This is a 20 times concentration error.Maximum peripheral concentration is 80 mEq/L.

This is a 5 times concentration error.

Dose should have been in the range of 6 mEq given over 2 hours to 12 mEq given 3.5 hours as 20mmol/L solution.

EVERY thing about this order was WRONG

and yet it reached a patient, my son.

Post-Scope

So why did this happen?Multifactorial

Rushing to get scope done before GI retiredLogan had less sodium that day than usual due to being at daycare and travelling unexpectedly to SaskatoonOrder for accurate ins/outs not initiated upon arrival to hospitalResident unfamiliar with NDINo nephrology officially on callIatrogenic lowering of potassium (2.7)Anesthesia was not aware that Logan had NDIOR was running earlyToo many physicians (Resident, Nephrologist, Gastroenterologist, Anesthetist)No pharmacist check of orderConcentrated potassium available on the wardDouble check (high alert drug) done but unclear on what double check all entailed for second signature by RNRushing, rushing, rushing!

What was done right?We Stopped the Line right then!Handled incredibly well by the entire team and health region

Apologies immediatelyInternal meetings and changes the very next morningChanges in solutions available on wards in following monthsChanges in how potassium is ordered and givenEducation of all partiesFollow up meetings with departments

Debrief with me! Communication when errors occur is critically importantHelps with healing

Follow up counseling for Logan and for myselfOngoing communication from the health region

Be the Change

https://youtu.be/pcQUnGiuhzM

It’s more than just people:

Technology can make our systems safer

Importance of Dose Error Reduction System (DERS)

Prescribing 39% Transcribing 12% Dispensing 11% Administering 38%

Source of errors

Errors intercepted

48% 33% 33% 2%

Leape, et al., JAMA, 1995

Wardstock

Fictional Example As RN was in a hurry she

didn’t fax to pharmacy nor call for a stat

She found a “hidden” bag of potassium 20 mmol/100mL and decided to use it as she was rushing to get child to OR

RN chooses a CCA based on child’s weight

Searches by POT Sees only 2 options, one

which is clearly labeled as central line only

In her haste she missed the note about central line

She enters the parameters from the order so she can give the 20 mmol over 30 minutes as ordered

The DERS ‘back-calculates’ based on the weight, duration and VTBI

It calculates a dose of 3.36 mmol/kg/hr

A hard limit is reached and she can not start the pump until parameters are reprogrammed

What parents want you to know

When the parents say "This thing about my child is different than most kids", listen to them.Little did we know, a few years later we would not only get the NDI diagnosis but now our son would be permanently catheterized at 7 years old because of all those Doctor's, Specialists and Nurses who refused to listen.I would ask them to do their due diligence when confronted with a rare condition like NDI. A simple Google search would provide them with some valuable info. Do not assume your degree and education are enough - please do some research. Even a Google search of symptoms could yield crucial info.

Reference: NDI Facebook Page

What parents want you to know

I would say if you do not know what a particular disorder or disease is, please don't google it and then act like you know what you're talking about. On multiple instances they would talk to me about CDI, just admit you have no clue. I respect you more for being honest and trying to come to a solution with me, than to lie to me and pretend like you know what you're talking about. Just because you're a doctor doesn't mean I expect you to know.Listen. If a mother says NO have a bit of trust. Not every patient is a horse. Some are zebras.

Reference: NDI Facebook Page

What I want you to knowLISTEN to patients and families when they tell you something is

wrong.Pharmacists and technicians are integral to patient safety. Optimizing therapy and being amazing clinicians means nothing if patients do not receive the right drug, at the right dose, at the right time. Safety happens at every stage in the drug distribution system.Stop the Line

Even when it is hard, you must speak up for your patients every single time. In our case seconds and minutes counted and there was no time to completely review the situation appropriately before making a plan. Stop the situation and fix it before proceeding. Our perfectionist personas can’t get in the way of stopping unsafe situations.

My ultimate wish is the metamorphosis of health care into a truly safe place for all our loved ones. One where the only worry parents have during the admission of their child is loving and snuggling them, not being on constant error watch. We have a long way to go but we can all make changes every day to make this a reality.

Logan is alive because we Stopped the Line

Thank you for listening to our story