Identifying Safety Hazards Associated With Intravenous Vancomycin Through the Analysis of Patient Safety Event Reports
DOI:
https://doi.org/10.33940/data/2020.3.3Keywords:
patient safety event, medication safety, vancomycin, human factorsAbstract
Intravenous (IV) vancomycin is one of the most commonly used antibiotics in U.S. hospitals. There are several complexities associated with IV vancomycin use, including the need to have an accurate patient weight for dosing, to provide close monitoring to ensure appropriate drug levels, to monitor renal function, and to continue delivery of the medication at prescribed intervals. There are numerous healthcare system factors, including workflow processes, policies, health information technology, and clinical knowledge that impact the safe use of IV vancomycin. Past literature has identified several safety hazards associated with IV vancomycin use and there are some proposed solutions. Despite this literature, IV vancomycin–related safety issues persist. We analyzed patient safety event reports describing IV vancomycin–related issues in order to identify where in the medication process these issues were appearing, the type of medication error associated with each report, and general contributing factor themes. Our results demonstrate that recent safety reports are aligned with the issues already identified in the literature, suggesting that improvements discussed in the literature have not translated to clinical practice. Based on our analysis and current literature, we have developed a shareable infographic to improve clinician awareness of the complications and safety hazards associated with IV vancomycin and a self-assessment tool to support identification of opportunities to improve patient safety during IV vancomycin therapy. We also recommend development of clear guidelines to optimize health information technology systems to better support safe IV vancomycin use.
References
Center for Disease Control and Prevention. Antibiotic Use in the United States, 2017: Progress and Opportunities. US Dep Heal Hum Serv. 2017:1-40. doi:10.1073/pnas.1417106112
Rybak M, Lomaestro B, Rotschafer JC, et al. Therapeutic Monitoring of Vancomycin in Adult Patients: A Consensus Review of the American Society of Health-System Pharmacists, the Infec-tious Diseases Society of America, and the Soci-ety of Infectious Diseases Pharmacists. Am J Heal Pharm. 2009;66(1):82-98. doi:10.2146/ajhp080434
Matsumoto K, Takesue Y, Ohmagari N, et al. Practice Guidelines for Therapeutic Drug Monitoring of Vancomycin: A Consensus Review of the Japanese Society of Chemotherapy and the Japanese Society of Therapeutic Drug Monitoring. J Infect Chemother. 2013;19(3):365-380. doi:10.1007/s10156-013-0599-4
Stanford Hospital & Clinics Vancomycin Dosing Guidelines 2013.; 2013. http://med.stanford.edu/content/dam/sm/bugsanddrugs/documents/dosing/2013VancomycinDosingGuide.pdf. Accessed February 6, 2020.
Martín-Navarro J, Petkov-Stoyanov V, Gutiérrez-Sánchez MJ. Letters to the Editor Rapid Response to High and Plasma Cells Efficacy of High Permeability Haemodialysis in Acute Renal Failure Due To. 2014:3-5. doi:10.3265/Nefrologia.pre2014.Jun.12108
Walczyk MH, Hill D, Arai A, Wolfson M. Acute Renal Failure Owing to Inadvertent Vancomycin Overdose Vancomycin Removal by Continuous Arteriovenous Hemofiltration. 1988;18(6):440-443.
Wilson FP, Berns JS. Vancomycin Levels are Frequently Subtherapeutic During Continuous Venovenous Hemodialysis (CVVHD). Clin Nephrol. 2012;77(04):329-331. doi:10.5414/CN106993
Bakke V, Sporsem H, Von der Lippe E, et al. Vancomycin Levels are Frequently Subthera-peutic in Critically Ill Patients: A Prospective Observational Study. Acta Anaesthesiol Scand. 2017;61(6):627-635. doi:10.1111/aas.12897
Bond CA, Raehl CL. Clinical and Economic Outcomes of Pharmacist-Managed Aminoglyco-side or Vancomycin Therapy. Am J Heal Pharm. 2005;62(15):1596-1605. doi:10.2146/ajhp040555
Iwamoto T, Kagawa Y, Kojima M. Clinical Efficacy of Therapeutic Drug Monitoring in Patients Receiving Vancomycin. Biol Pharm Bull. 2003;26(6):876-879. doi:10.1248/bpb.26.876
Cardile AP, Tan C, Lustik MB, et al. Opti-mization of Time to Initial Vancomycin Target Trough Improves Clinical Outcomes. Springerplus. 2015;4(1):364. doi:10.1186/s40064-015-1146-9
Hall AB, Montero J, Cobian J, Regan T. The Effects of an Electronic Order Set on Van-comycin Dosing in the ED. Am J Emerg Med. 2015;33(1):92-94. doi:10.1016/j.ajem.2014.09.049
Wong-Beringer A. Failure to Reevaluate. AHRQ Patient Safety Network. https://psnet.ahrq.gov/web-mm/failure-reevaluate. Published 2010. Accessed October 7, 2019.
Fuchs A, Csajka C, Thoma Y, Buclin T, Widmer N. Benchmarking Therapeutic Drug Monitoring Software: A Review of Avail-able Computer Tools. Clin Pharmacokinet. 2013;52(1):9-22. doi:10.1007/s40262-012-0020-y
Roszell S, Jones C. Intravenous Admin-istration Issues. J Infus Nurs. 2010;33(2):112-118. doi:10.1097/nan.0b013e3181cfcee4
Caparas J V., Hu JP. Safe Administration of Vancomycin Through a Novel Midline Catheter: A Randomized, Prospective Clinical Trial. J Vasc Access. 2014;15(4):251-256. doi:10.5301/jva.5000220
Mowry JL, Hartman LS. Intravascular Throm-bophlebitis Related to the Peripheral Infusion of Amiodarone and Vancomycin. West J Nurs Res. 2011;33(3):457-471. doi:10.1177/0193945910380212
Moureau NL. Is the pH of Vancomycin an Indication for Central Venous Access? J Vasc Access. 2014;15(4):249-250. doi:10.5301/jva.5000223
Bruniera FR, Ferreira FM, Saviolli LRM, et al. The Use of Vancomycin With Its Ther-apeutic and Adverse Effects: A Review. Eur Rev Med Pharmacol Sci. 2015;19(4):694-700.
Sivagnanam S, Deleu D. Red man syndrome. Crit Care. 2003;7(2):119-120. doi:10.1186/cc1871
Wallace MR, Mascola JR, Iii ECO. Red Man Syndrome : Incidence , Etiology , and Prophy-laxis Author ( s ): Mark R . Wallace , John R . Mascola and Edward C . Oldfield III Published by : Oxford University Press Stable URL : http://www.jstor.org/stable/30111752 REFERENCES Linked references a. 2018;164(6):1180-1185.
Breland BD. Continuous Quality Im-provement Using Intelligent Infusion Pump Data Analysis. Am J Heal Pharm. 2010;67(17):1446-1455. doi:10.2146/ajhp090588
Crew P, Heintz SJ, Heintz BH. Vancomycin Dosing and Monitoring for Patients With End-Stage Renal Disease Receiving Intermittent Hemodialysis. Am J Heal Pharm. 2015;72(21):1856-1864. doi:10.2146/ajhp150051
Crowley RK, Fitzpatrick F, Solanki D, Fitz-Gerald S, Humphreys H, Smyth EG. Vancomycin Administration: The Impact of Multidisciplinary Interventions. J Clin Pathol. 2007;60(10):1155-1159. doi:10.1136/jcp.2006.044727
Fuller B, Nicholas M, Skrupky L, Mueller K, McCammon C. Emergency Department Vancomycin Use: Dosing Practices and Associ-ated Outcomes. J Emerg Med. 2013;44(5):1-17.
Raverdy V, Ampe E, Hecq JD, Tulkens PM. Stability and Compatibility of Van-comycin for Administration by Continuous Infusion. J Antimicrob Chemother. 2013;68(5):1179-1182. doi:10.1093/jac/dks510
Burgess LD, Drew RH. Comparison of the Incidence of Vancomycin-Induced Nephro-toxicity in Hospitalized Patients with and without Concomitant Piperacillin-Tazobact-am. Pharmacother J Hum Pharmacol Drug Ther. 2014;34(7):670-676. doi:10.1002/phar.1442
Gomes DM, Smotherman C, Birch A, et al. Comparison of Acute Kidney Injury During Treatment with Vancomycin in Combination with Piperacillin-Tazobactam or Cefepime. Pharmacother J Hum Pharmacol Drug Ther. 2014;34(7):662-669. doi:10.1002/phar.1428
Hundeshagen G, Herndon DN, Capek KD, et al. Co-administration of Vancomycin and Piperacillin-Tazobactam is Associated With Increased Renal Dysfunction in Adult and Pediatric Burn Patients. Crit Care. 2017;21(1):1-10. doi:10.1186/s13054-017-1899-3
Linsenmeyer K, Strymish JM, Smith D, Brennan M, Gupta K. Electronic Consults for Improving Vancomycin Use. J Hosp Infect. 2018;99(2):158-159. doi:10.1016/j.jhin.2017.12.002
Holly C, Poletick EB. A Systematic Review on the Transfer of Information During Nurse Transitions in Care. J Clin Nurs. 2014;23(17-18):2387-2396. doi:10.1111/jocn.12365
Spencer R, Coiera E, Logan P. Variation in Communication Loads on Clinical Staff in the Emergency Department. Ann Emerg Med. 2004;44(3):268-273. doi:10.1016/j.annemergmed.2004.04.006
Van Der Luit CD, De Jong IR, Ebbens MM, et al. Frequency of Occurrence of Medication Discrepancies and Associated Risk Factors in Cases of Acute Hospital Admission. Pharm Pract (Granada). 16(4):1301. doi:10.18549/PharmPract.2018.04.1301
Pope C, Ziebland S, Mays N. Qualitative research in health care. Analysing qualitative data. Br Med J 2000;320:114–16.
Kohler DR, Montello M, Goldspiel BR, et al. ASHP Guidelines on Preventing Medication Errors with Antineoplastic Agents. Am J Heal Pharm. 2002;59(17):1648-1668. doi:10.1093/ajhp/59.17.1648
NCC MERP. NCC MERP taxonomy of medication errors. Prevention. 1998:1-19. https://www.nccmerp.org/sites/default/files/taxono-my2001-07-31.pdf. Accessed October 7, 2019.
Hall AB, Montero J, Cobian J, Regan T. The Effects of an Electronic Order Set on Van-comycin Dosing in the ED. Am J Emerg Med. 2015;33(1):92-94. doi:10.1016/j.ajem.2014.09.049
Mishra V, Chouinard M, Keiser J, et al. Automating Vancomycin Monitoring to Improve Patient Safety. Jt Comm J Qual Patient Saf. September 2019. doi:10.1016/j.jcjq.2019.07.001
