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.
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.
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.
Surgical fires: decreasing incidence relies on continued prevention efforts. - Bruley ME, Arnold TV, Finley E, Deutsch ES, Treadwell JR. PA-PSRS Pa Patient Saf Advis. June 2018;15.
2 days ago