Medication incidents involving immunosuppressive agents
Canadian Pharmacists Conference ePoster Library. Ho C. Jun 25, 2016; 132150
Dr. Certina Ho
Dr. Certina Ho
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Abstract
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OBJECTIVES: Immunosuppressants are potent, immune-modulating medications that can cause significant harm to patients if used incorrectly. The objective of this multi-incident analysis is to assess the challenges of managing immunosuppressive therapy in the community setting and identifying system-based vulnerabilities.,METHODS: Oral immunosuppressive agents of interest, such as Azathioprine and Cyclosporine, were retrieved from the American Hospital Formulary Service classification system. Intravenous agents were excluded due to a lack of presence in the community setting. Relevant medication incidents were gathered from the ISMP Canada's Community Pharmacy Incident Reporting (CPhIR) Program between January 2010 and May 2015. From an initial collection of 61 cases, a total of 47 medication incidents met inclusion criteria and were analyzed and reviewed by two analysts independently.,RESULTS: Quantitative analysis found that of the initial 61 medication incidents, 59% (36) were near-misses, 18% (11) resulted in no harm, and 3% (2) resulted in mild harm to the patient. The remaining 20% (12) were excluded due to insufficient narrative information provided by the reporter. Qualitative analysis uncovered three major themes that ran prevalent throughout all 47 incidents: (1) indication, (2) effectiveness, and (3) safety. Indication referred to incidents where an incorrect drug was being prescribed or dispensed due to look-alike/sound-alike names and/or formulation oversight. Effectiveness primarily focused on medication errors arising from sub-therapeutic dosing that resulted in therapy failure, while safety referred to incidents that resulted in toxicity due to either supra-therapeutic dosing or drug interactions. System-based vulnerabilities included factors such as confirmation bias, practitioner's knowledge gap, and lack of independent double checks in pharmacy workflow.,CONCLUSIONS: Immunosuppressive agents are commonly used by all patient populations within the community. Analysis of medication incidents provides an opportunity for health care practitioners to learn from errors and advance safe medication practices for quality patient care.
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