Patient Safety in the Emergency Department
Medication Safety
Case Scenario 1
A 65-year-old woman presented to the ED with atrial fibrillation with a rapid ventricular rate of 165 beats/minute. Her heart rate was controlled with intravenous (IV) diltiazem, and a heparin infusion was ordered based on her estimated weight of 150 lb. As the pharmacist prepared the infusion, she rechecked the patient’s weight and discovered that the heparin order had been placed using pounds instead of kilograms. The pharmacist discussed the order with the physician, and the order was changed to avoid a double-dosing error.
Discussion
Many medications are required to treat critical illnesses and complex medical conditions; such polypharmacy is further complicated by the sheer volume of patients seen in the ED. The wide range of medications used in the ED and the different doses appropriate for age, gender, and body weight can lead to patient harm when the prescriber is confused. In addition, many medications can be administered via multiple routes, including IV, intramuscular, subcutaneous, or oral. In situations where a critically ill patient is close to death, verbal orders are often used and then followed by computer orders when the physician is able to leave the bedside. Clinicians may be simultaneously treating multiple patients with similar conditions or with similar names. In addition, due to the acuity of patient complaints, “high-alert” medications are often used in the ED,14 such as paralytics, opioids, anticoagulants, antithrombotics, insulins, sedatives, and vasopressors.15 Considering all of these factors, it is not surprising that up to 60% of ED patients experienced medication errors in one study.16 Fortunately, most of these errors do not result in immediate patient harm, but have the potential to lead to harm.17
The addition of a pharmacist to the ED 24 hours a day, 7 days a week can greatly improve medication safety. Emergency department pharmacists are available for immediate bedside consultation or discussion of a medication order, and can intercept prescribing errors in the ordering system before they are administered and before they result in patient harm.18 In general, medication errors are 13.5 times less likely to occur when a pharmacist is on duty in the ED.19 Pharmacists can recommend appropriate antibiotic dosing,20 as well as aid in the timely administration of medications for such emergent conditions and procedures as stroke, MI, trauma, and rapid-sequence intubation. In our ED, the pharmacists also ensure that look-alike/sound-alike (LASA) medications are not confused. Importantly, in overcrowded EDs, the pharmacist reviews medication orders for all inpatients boarding in the ED and ensures that the nurses obtain the appropriate medications from the automated dispensing cabinets. In some instances, neither the EP nor the ED nurses may be familiar with proper doses and scheduling of medications typically used only in the inpatient service.
Pharmacists can prevent errors with formulation confusion, LASA confusion, weight-based dose errors, and dosing frequency errors. They also can ensure that the most up-to-date evidence is used to support a medication ordered, ensuring best practices and adherence to hospital policies. Table 214 summarizes additional information on best practices for medication safety in the ED.
Discharge Process
Case Scenario 2
A 55-year-old man on warfarin presented to the ED with cough, dyspnea, and fever. His chest X-ray revealed right lower lobe pneumonia. He was prescribed levofloxacin and discharged home. His discharge instructions included a discussion of pneumonia, fever control, and the importance of taking his antibiotic appropriately, but he was not told to have his international normalized ratio (INR) checked regularly while taking levofloxacin. When the patient returned to the ED 5 days later because of rectal bleeding, his INR was elevated to 6 (normal range in a patient taking warfarin is 2.0-3.0).
Discussion
When patients who do not require admission to the hospital are discharged home, they need instructions to ensure that they fully understand the nature of their problem and what they need to do to get better. For the provider, the discharge process must include three tasks: communicating crucial information (diagnosis and return precautions), verifying the patient’s comprehension of the information presented, and addressing and correcting specific concerns and misunderstandings.21 The encounter must be standardized but also be flexible enough to ensure patient understanding across a wide range of health care literacy and cultural backgrounds.21 Patients frequently are not given appropriate verbal and written instructions, and if they do not understand their diagnosis, they may not follow up when necessary; may not realize that they need to take specific medications; or may not take their newly prescribed medications as intended.
