Requesting Reports on BCMA Safety Concerns

VA personnel are invited to submit PSRS reports to NASA describing BCMA events, close calls, or safety concerns. Reports will be de-identified and will contribute to an upcoming VA Breakthrough Collaborative Series sponsored by VA NCPS, BCMA Program Office, and NASA PSRS. Reports could include issues such as:

• Ordering
• Transcribing
• Preparing
• Dispensing and administration
• Interfacing with Pharmacy and CPRS

Recipe for Leftovers

Changing computerized medication orders can cause a significant unintended and unrecognized effect when a portion of the previous order remains in the system. A physician discovered the following when reducing a warfarin dose for a patient with an elevated prothrombin time:

• “I used the electronic medical record system (CPRS) to make the changes to his medications. I highlighted the order and selected the change medication option. I then changed the daily dose to 3.0 mg/d, signed and released the order. Either unnoticed by me, or unknown to me, a second line of instructions from the prior order remained in the new prescription... This could have serious adverse effects with unknown inappropriate dosing.”

The physician had an opportunity to correct the order when later contacted by a pharmacist.

• “This only came to my attention because the pharmacist did not have tablets available to fill the prescription, but was under the impression it should have been for the higher dose. The CPRS program should completely remove old prescription information when the script is changed.”

The physician discussed this safety hazard with the pharmacy, the laboratory, and the facility information technology person involved with CPRS.

Adverse reactions occur in about 5% of contrast media examinations. Severe side effects, such as asthma or anaphylaxis, occur less commonly than mild reactions such as flushing, nausea, and headache (Allergy. 2000 Jun;55(6): 581-2). A reporter described a near miss when a patient almost received an x-ray contrast dye to which he had a known allergy.

• “Patient directed to report to Radiology for x-ray procedure... X-ray technician asked just before inserting needle 'Are you allergic to anything?' Patient replied, 'Yes, Optiray 300 injection.'”

The x-ray technician did not give the injection already drawn up for that patient. The lack of information about patient allergies was explained:

• “Radiology does not receive record of patients to be x-rayed! Info on these patients is available on computer.”

However, the computers are located far from the x-ray examination room, and are not routinely checked prior to a procedure. The reporter had a suggestion for preventing similar occurrences:

• “Have a special card printed at each registration encounter that lists the date, the reason for the visit, as well as patient's regular medications and allergies.”

The reporter also expressed concern for elderly veterans:

• “They don't always remember their reason for the visit, their medications, and many times do not respond clearly to the 'Are you allergic?' question.”

Most gastroenterologists (71% to 82%) discontinue oral anticoagulant (OAC) therapy prior to performing colonoscopies (Gastrointest Endosc. 1996 Sep;44(3):309-16). A more recent review of 31 studies did not find published reports of major bleeding while receiving therapeutic OAC for patients undergoing colonoscopy with or without biopsy, but stressed that the pre-operative strategy should be individualized (Arch Intern Med. 2003 Apr 28;163(8):901-8).

A reporter described the outcome of a colonoscopy with biopsy performed without knowledge of the patient's OAC status. The patient traveled to the medical center from the vet center in which he lived. Since the clinician wanted to rule out a lower colon tumor:

• “It was decided to perform a rectal biopsy on the patient. The electronic record was reviewed for medications. None were listed because the vet center opted not to enter patient meds into the computerized record and there was no qualifier alert on the patient's med screen warning that no meds were entered. Actually the patient was on coumadin and the biopsy caused excessive bleeding.”

The reporter noted that one might prevent future reoccurrences by:

• “Asking the patient, 'What meds are you on?' [or] checking the hardcopy record. (Note - if the vet center knows there is a procedure scheduled they send the medication record. This was an unplanned procedure.)”

A reporter cautioned that potentially permanent adverse effects can arise from prescribing compazine (prochlorperazine) for long term use, quoting from Micromedex:

• “The use of neuroleptic drugs, such as prochlorperazine, is a risk factor for the development of tardive dyskinesia. This risk of developing the syndrome increases with duration of treatment and total cumulative dose...However, any patient may be at risk to develop the syndrome, even after a comparatively brief treatment period at a low dose.”

Finding two patients in three months who had developed tardive dyskinesia after prolonged use of compazine, the clinicians took action:

• “We have added to our drug file nomenclature: 'Compazine is only indicated for short duration due to risk of tardive dyskinesia with long term use.' And, for quick orders, 'Long term use may be associated with tardive dyskinesia.' We have additionally run a list of all patients with active compazine prescriptions and will be evaluating those cases as well. Our Pharmacy and Therapeutics Committee is considering the issue during their meeting and may recommend refill limitations.”

The complex tasks of anesthesia require sustained attention and are particularly vulnerable to the effects of fatigue (Anesthesiology. 2002 Nov;97(5):1281-94). While concluding a rotation of weekend on call, an anesthesiologist discovered the performance effects of not getting adequate sleep.

• “The last case... began [in the early hours of Monday morning] and ended 1 1/2 hours later. Delayed emergence secondary to anesthetic agent being left on. (Volatile anesthetic off - nitrous oxide on.) Possibly (probably!) fatigue related. After noticing (after 5 minutes) nitrous oxide discontinued and patient awakened. Impaired decision making at early morning hour.”

The reporter was supervising a co-worker who had also been up most of the night. Each thought the other person had turned off the nitrous oxide.