Monday, June 18, 2007

Lack of information support: impact on safety

To support any discussions about the importance of having information and knowledge expertise available to support patient care, I share this analysis from my colleagues from the National Center for Patient Safety, who noted that in this recent ISMP analysis:

Fluorouracil Incident Root Cause Analysis Report.
Toronto, ON, Canada: Institute for Safe Medication Practices Canada. May 8, 2007.
http://psnet.ahrq.gov/resource.aspx?resourceID=5382

The lack of depth of information available in patient care is what struck them as they read this report. They state that sometimes you just have to get experts (like poison control people and information folks) into the mix because not all these things are easy to find by doing typical searches.

See Page 21 of the report(4th bullet most applicable)

Lack of information on medical management of previous fluorouracil overdoses

Information about the medical management of fluorouracil overdose was not readily available.

• Information about previous similar incidents is difficult to find or not available. The medical literature contains only scattered anecdotal reports. --Depends where you look.

• Sharing of information about adverse events in health care is not well developed.
Information in reporting programs for medication and device incidents is not transparent and is not consistently categorized using the same taxonomy, which increases the difficulty of accessing the limited information that is available. Again, depends where you look. Meyler's Side Effects of Drugs has all this information, easily retrievable. Information professionals are familiar with more resources than are other healthcare professionals.

• There is no standard definition for chemotherapy “overdose”. Fixed dose limits by agent cannot be reached because the drugs are dosed on an individual basis and the dosing rules vary by regimen.

• A poison information centre was not contacted for assistance. Immediate notification of a poison information centre might have yielded useful initial guidance and access to toxicology experts.

PAGE 35

Fluorouracil drug monograph not available in Compendium of Pharmaceuticals and Specialties

In the course of researching background information on fluorouracil, it was discovered that the Canadian manufacturer of fluorouracil injection, Mayne Pharma, has opted to include only a product description (instead of a complete monograph) in the Compendium of Pharmaceuticals and Specialties (CPS). As the CPS is often a “first check” source of drug information for health care professionals, this omission may make it more difficult for practitioners to quickly obtain information about potential adverse effects and management of toxic effects. A copy of the product monograph is included as a package insert with each vial of product; however this does not ensure availability of information to the end user for products (such as fluorouracil) that must be premixed by the pharmacy before dispensing.

4 comments:

Lorri Zipperer said...

Reposted by permission:

Jeannine writes:

Sounds really good. For adverse drug info, I always go to Meyler's Side Effects of Drugs, which is only in print. Side Effects of Drugs Annual updates it between editions. Even if a library doesn't have it, (because it's expensive) knowing it exists and knowing which other libraries have it and can fax over a copy of the relevant section can help a great deal. It is a compendium of all adverse effects info (from any source) on any given drug. Our pharmacists consult it when their sources don't have an answer.
Of course, there's the Ellen Roche case, in which the information about hexamethonium was right there in Micromedex, and the researcher didn't look there, he looked in PubMed, Google and (I think) LookSmart. This case is a perfect illustration. JC knows of it already, I'm sure, but it points out that even with point of care tools, docs don't look in the right ones. Adding this in with the new Canadian case would strengthen the argument. There's an article called "Could a librarian have saved a patient's life/" or something like that. Let me know if you need a reference to it.

Here's another example, probably not strong enough to use with the JC, but showing that these are not isolated cases. One of our MD's asked me if his male patient's use of danazol could be the cause of infertility. 99% of non-info professionals would look in the past several years' worth of literature. Some would limit to English, probably not all of them--if they were using a database that gave them a choice. How many of them would have found the two articles in French from the 1970's and 1980's reporting on trials of the use of danazol as a male contraceptive? (I did.) Using the term "infertility" didn't get one anywhere near this article. And it used whichever form of the drug name was NOT the one the doctor gave me. He was very grateful, since he was now confident of the source of the problem. This is, basically, the same as the Ellen Roche case--except that Dr. Wasser didn't try to do his own search, and here, only the patient's fertility, not his life, were at stake.

CAPS [www.patientsafety.org] knows of a lot of patient safety cases. Could we look them over to see if any are related to lack of this type of information? Maybe we'd have to get permission of the person involved to use the case in our argument.

─Jeannine

Lorri Zipperer said...
This comment has been removed by the author.
Lorri Zipperer said...

I am aware of the Roche case, Linda Williams and I use it all the time as our "Case" example of trying to illustrate the types of small information failures that could ultimately contribute to a sentinel event. I was also going to use it as an illustration of risks that could arise if information decisions aren't made from a systems thinking perspective in our SLA class that got cancelled. For me its the "Libby Zion" of our field in seeing that our work affects the safety of patients.

There is another instance of a documented failure / medication error related death involving old drug books that ISMP investigated: the Denver Nurses case. I think they describe all that in this Hosp Pharm article: http://psnet.ahrq.gov/resource.aspx?resourceID=1500

I really like the idea of tying an argument to patient safety if we can do it. I don't know if my and Jan Sykes small study on the librarians role would be of any help to mention: http://www.pubmedcentral.nih.gov/picrender.fcgi?action=stream&blobtype=pdf&artid=521523.

Rainyland said...

Yes! Very useful textbooks. But a bit expensive. I get the book from a discount bookstore and it only about 50% off discount. The textbook is brand new. That's great. See if the web are useful for you

http://www.cocomartini.com/rainyland/product_info.php?products_id=1766

Meyler's Side Effects of Drugs: The International Encyclopedia of Adverse Drug Reactions and Interactions 6 Volume Set, 15th Edi