Critical Connections: Unravelling Adverse Drug Reactions and IV Incompatibility in High-Risk Medications

Abstract

Background & Objectives: Adverse Drug Reactions (ADRs) and Intravenous (IV) incompatibilities are critical concerns in clinical settings as they can affect patient safety and the effectiveness of treatment. This study investigates the frequency and types of ADRs and IV incompatibilities associated with High-Risk Medications (HRMs) in a tertiary care hospital and offers recommendations for preventing these issues. Methods: A six-month prospective observational study was conducted across the General Medicine, Cardiology, and Intensive Care Unit departments of a 1000-bed teaching hospital to assess ADRs and IV incompatibilities related to HRMs. Results: Out of 97 prescriptions, 27 ADRs were identified, with heparin being the most frequent cause (51.5%), followed by insulin (47.5%) and potassium chloride (45.4%). Heparin-related ADRs primarily included hematuria (50%), decreased hemoglobin (25%), rashes (12.5%), and thrombophlebitis (12.5%). Insulin was associated with five hypoglycemic episodes. Potassium chloride caused vomiting (50%) and thrombophlebitis (50%). Additionally, 230 IV infusion errors were noted, with the most common errors being unrecorded diluent (44%), unrecorded infusion rate (32%), unrecorded concentration (23%), and four cases of IV drug incompatibilities (2%). Interpretation & Conclusion: The study underscores the necessity for improved prescribing practices and adherence to guidelines. It also suggests implementing targeted interventions and enhancing pharmacovigilance to improve patient safety and treatment effectiveness.

Keywords

Introduction

Figure:1 Distribution of High-Risk Medication Prescriptions Based on Age (N=97)

Table:3 Adverse Drug Reactions of High-Risk Medications (n = 27)

Figure 2: Categorisation Of Iv Infusion Errors with High-Risk Medications (N=230)

Table 4: High Risk Medication with IV Infusion Errors (N=230)

DISCUSSION

The present observational study established the adverse drug reaction profile and causality assessment of High-risk medications with Naranjo scale.^[5] A total of 97 prescriptions were analyzed. The current study reported a majority of people with use of HRM were ≥ 60 years, similar to the study of Subbiah et al ^[23]. Our study highlights male population were more frequently prescribed with HRM and affected, which was in par with the results of study conducted by Arjun et al, (2012).^[24] This study was conducted in three major departments selected through a pilot study, which includes cardiology, ICU and general medicine among which ICU accounted for 63% followed by general medicine 19%, and cardiology 18%. Analyzing 97 prescriptions, we could identify 27 ADRs with the use of High-Risk medications in which heparin ranks first with highest number of ADRs (29.7%), followed by insulin (18.5%) and potassium chloride (14.8%). The major reactions observed with the use of heparin was hematuria (50%) which is probable, other reactions such as decreased hemoglobin (25%), rashes (12.5%) and thrombophlebitis (12.5%) falls under possible range calculated using Naranjo scale. All these results coincide with the study conducted by Piazza G. et al ^[9].Insulin was the second most frequently prescribed drug that resulted in ADR, where it caused five episodes of hypoglycemia after administration where all the events were probable, which is similar to the results of Shanthi G ^[20] in which the highest ADR recorded was hypoglycemia. Thereafter, patients receiving potassium chloride suffered from vomiting (50%) and thrombophlebitis (50%) classified under possible range.  Most of the errors reported in our study falls under mild to moderate class and some of the errors were not preventable. These findings were also observed in the study conducted by Kassere S et al, where no severe ADR was reported.^[12] This study also evaluated the use of IV infusion of HRM and the associated errors. Upon analyzing 97 medication charts, 230 errors were identified, which is similar to a study conducted by Marsilio et al., where 100 medication charts were analyzed, revealing 68% IV incompatibilities ^[21]. We categorized the IV incompatibilities into diluent unrecorded, followed by infusion rate unrecorded, concentration unrecorded, and IV incompatibility. These findings were compared to a similar study on errors associated with IV infusion in critical care conducted by Summa Sorgini et al. ^[17]. Definitions of errors were established a priori based on the policies and practices at the study site ^[17]. According to the categorization, 'diluent unrecorded' accounted for the highest number of errors, with 101 errors (44%), followed by 'infusion rate unrecorded' with 73 errors (32%), 'concentration unrecorded' with 52 errors (23%), and IV incompatibilities noted in 4 drugs (2%). These IV incompatibilities were analyzed and resolved using the Micromedex Drug Database And Lexi drug as references, both available through the Department of Pharmacy Practice. In our study, 29 (87.8%) probable IV incompatibilities were identified and prevented, while only 4 (12.2%) definite incompatibilities occurred. In a study conducted by Marsilio et al. ^[21], midazolam and cefepime were identified as the most common incompatible drug pair. In our study, pantoprazole, commonly prescribed for gastrointestinal disorders, was found to be frequently incompatible with xenobiotics, followed by analgesics. Additionally, the improper selection of diluent solutions (e.g., Ringer’s lactate solution containing calcium chloride) increases the risk of forming calcium crystals when mixed with ceftriaxone. These drug incompatibilities were commonly observed with frequently used medications such as pantoprazole and ceftriaxone. Therefore, teaching sessions should be provided to nurses to raise awareness before administering these drugs. Attention must be paid to preventing such errors, and strategies should be developed to reduce the incidence of errors while handling all medicated solutions.

Recommendations For Improving Prescribing Practices

1. Training and Education: Proper training is keen while training nurses on recognizing ID, eliminating potential drug side effects (ADEs) and specifics of intravenous incompatibility. These sessions will also help in updating the latest guidelines and protocols.

2. Enforce Strict Adherence to STGs: Implementing HOSPITAL-specific standard treatment guidelines (STGs) and ensuring compliance through periodic audits. Policies could be enforced in the form of penalties on non-compliance as well as rewards for adherence to encourage full adoption.

3.E- systems can be used: (e-prescribing): Prescription of drugs based on a system with detecting drug interactions, incompatibility of IV and ADRs while giving orders which will enable the correction to avoid adverse effects as soon as possible.

4.Pharmacovigilance Programs: Developing comprehensive pharmacovigilance programs to track and reduce reporting of ADRs. They work early to get into the detection, reporting and preventing while affecting patient’s health.

5.Patient Education: Proper education of patients about the risks of the drugs especially high-risk medications and prompt reporting of adverse events can be beneficial for early detection and management.

CONCLUSION:

High-risk medications are drugs that bear a heightened risk of causing significant patient harm while they are used in error. The consequences of error are more devastating to patients. When any medication can potentially cause harm, a selected group of drugs “High-Risk Medications (HRMs)” carries a higher risk of patient injury. From the results obtained from study revealed that Continued surveillance and documentation of ADRs should be prioritized, and healthcare providers should be vigilant in recognizing potential ADRs during treatment. To minimize the risk of IV incompatibility, Prescription of drugs should be based on a system with detecting drug interactions, incompatibility of IV and ADRs while giving orders which will enable the correction and prevention of errors. These findings provide valuable insights for healthcare providers aiming for improvised medication safety practices in a tertiary care hospital.

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