Prostacyclin Errors Rampant In PAH Patients
SAN DIEGO — Serious errors in prostacyclin infusion therapy are extremely common even at large pulmonary arterial hypertension centers, according to a national survey.
“These findings suggest that infusion therapy for pulmonary hypertension is problematic and that an opportunity exists to improve safety. The development of treatment standards of care and/or guidelines should be considered,” Martha S. Kingman, R.N., concluded at the annual meeting of the American College of Chest Physicians.
The national survey, partly funded by the North and Central Texas Clinical and Translational Science Initiative, involved detailed in-depth interviews with nurses at 18 large PAH treatment centers, as well as an electronic questionnaire completed by physicians and other health care providers with a special interest in PAH.
Serious or potentially serious errors in prostacyclin administration were reported by nurses at 17 of 18 (94%) of the large PAH centers. The errors included major miscalculations of dosing, giving one patient the dose intended for another, and flushing of the dedicated infusion line. Three deaths resulted.
A total of 68 of 97 respondents to the electronic questionnaire also reported encountering major prostacyclin infusion errors. These errors had serious consequences in 28 cases, including 9 deaths, according to Ms. Kingman, a nurse practitioner at the University of Texas Southwestern Medical Center, Dallas.
She cited several likely reasons for the high medication error rate. The cassettes for epoprostenol (Flolan) and treprostinil (Remodulin) are identical in appearance, they can't be stored in automated dispensing systems, a multitude of drug concentrations are available, and the therapeutic dosing range for any individual patient is quite narrow.
The most critical factor, however, is undoubtedly the lack of standard formal hospital policies or guidelines for prostacyclin administration, she said.
Ms. Kingman reported having received honoraria from United Technologies and Gilead Sciences, which market intravenous prostacyclins.
