Reminding staff of diligence during the medication process is not enough to ensure safety : Learning from wrong fluid product selection incidents in the care of critically ill patients

Background and objectives: Wrong fluid product selection may cause harm to patients. This study aimed to describe voluntarily reported wrong fluid product selection incidents, including their consequences, the reported latent conditions and active failures leading to these and the suggested safeguards to prevent their occurrence, and to compare the suggested and literature-based safeguards to improve the fluid therapy safety within the intensive care (ICU) environment. Methods: All voluntarily and anonymously reported wrong fluid product selection incidents in all Finnish ICUs during 2007–2017 were reviewed. The incident reports included categorized data that were analyzed quantitatively, and narratives that were analyzed qualitatively, using content analysis. The results were reported as frequencies and percentages and described by using Reason's model of human error. Results: Over the eleven years, one wrong fluid product selection incident was reported every six days (n=663; 584 errors, 79 near misses); most were reported to have occurred during the dispensing/preparing phase (92%). Of the 584 reported selection errors, a quarter (26%) was reported to have caused consequences to patients, and one third (35%) to have required corrective or monitoring actions. The main reported latent conditions to the incidents were Working environment and resources (e.g. workload and time pressure) (29%), Similar-looking and -sounding names or shared features of the product containers (i.e. the LASA phenomenon) (28%) and Working methods (22%); and the main reported active failures were a lack of concentration, or forgetfulness (26%). Some usable suggestions of safeguards were made, e.g. optimizing fluid storage (15%) or utilizing checking practices (21%). While requiring accuracy, i.e. reminding staff of diligence and to be more attentive to detail during the whole medication process, was emphasized in most reports (71%), involving manufacturers in redesigning labels of fluid products, utilizing technology and strengthening pharmacy services are advocated existing literature. Conclusions: Wrong fluid product selection incidents with various latent conditions and active failures were reported more than once a week. To minimize the serious LASA phenomenon,multi-professional collaboration, coordinated international discussion and agreements of solutions with manufacturers, regulators and end-users, are needed. However, work is also needed to reduce the other latent factors, such as Working environment and resources as well as cognitive biases in daily work that may contribute to the occurrence of LASA related errors.Peer reviewe

Describing voluntarily reported fluid therapy incidents in the care of critically ill patients: Identifying, and learning from, points of risk at the national level

Background:Fluid therapy is a common intervention in critically ill patients. Fluid therapy errors may cause harm to patients. Thus, understanding of reported fluid therapy incidents is required in order to learn from them and develop protective measures, including utilizing expertise of pharmacists and technology to improve patient safety at the national level. Objectives:To describe fluid therapy incidents voluntarily reported in intensive care and high dependency units (ICUs) to a national incident reporting system, by investigating the error types,fluid products, consequences to patients and actions taken to alleviate them, and to identify at which phase of the medication process the incidents had occurred and had been detected. Methods:Medication related voluntarily reported incident (n= 7623) reports were obtained from all ICUs in2007–2017. Incidents concerning fluid therapy (n= 2201) were selected. The retrospective analysis utilized categorized data and narrative descriptions of the incidents. The results were expressed as frequencies and percentages. Results:Most voluntarily reported incidents had occurred during the dispensing/preparing phase(n= 1306, 59%) of the medication process: a point of risk. Most incidents (n= 1975, 90%) had reached the patient and passed through many phases in the medication process and nursing shift change checks before detection. One third of the errors (n=596,30%) were reported to have caused consequences to patients. One quarter (n= 492, 25%) of the errors were reported to have required an additional procedure to alleviate or monitor the consequences. Conclusions:Utilizing national incident report data enabled identifying systemic points of risk in the medication process and learning to improve patient safety. To prevent similar incidents, initial interventions should focus on the dispensing/preparing phase before implementing active medication identification procedures at each phase of the medication process and nursing shift changes. Strengthening clinical pharmacy services, utilizing technology, co-ordinated by IV Fluid Coordinators and Medication Safety Officers, could improve patient safety in the ICUs.Peer reviewe

Фармакокинетика теофиллина в ночное время при однократном приеме: сравнение трех препаратов в одинаковых условиях

We have carried out a stead y state pharmacokynetic comparison of three different theophylline preparations in nine healthy volunteers using a once a day dosage schedule of 600 mg theophylline given before bedtime for four days. The preparations tested were Retafyllin 200 mg depot tablet (R), Theo-Dur 200 mg depot tablet (T) and Uniphyllin 200 mg tablet (U). All preparations in steady state reached the serum level of 8.9— 10.2 microg/ml after a single evening dose of theophylline 600 mg. The pharmacokinetic profile of these slow release theophylline preparations was such that there is no risk of exceeding the therapeutic range even after a rather high evening dose. Individual variation was also observed in the present study but nobody exceeded the therapeutic range. The pharmacokinetic profiles of R and U were quite similar and they seemed to have suitable pharmacokinetic properties for once a day dosage, and they showed a more sustained action than T. Only minimal gastrointestinal side effects were reported during this study.

Ecological and genetic analysis of copper and streptomycin resistance in Pseudomonas syringae pv. syringae

Strains of Pseudomonas syringae pv. syringae resistant to copper, streptomycin, or both compounds were recovered from symptomless and diseased tissue of four woody hosts in three nurseries in Oklahoma. In strains resistant to copper and streptomycin (Cu^r Sm^r), resistance to both compounds was cotransferred with a single plasmid which was either 68, 190, or 220 kilobase pairs (kb). All Cu^s Sm^r strains contained a 68-kb conjugative plasmid. Cu^r Sm^s, strains contained one plasmid which varied in size from 60 to 73 kb. All conjugative plasmids which transferred streptomycin resistance contained sequences homologous to the strA and strB Sm^r genes from the broad-host-range plasmid RSF1010. The Sm^r determinant was subsequently cloned from a 68-kb Cu^r Sm^r plasmid designated pPSR1. A restriction map detailing the organization of the homologous Sm^r genes from pPSR1 and RSF1010 and cloned Sm^r genes from P. syringae pv. papulans and Xanthomonas campestris pv. vesicatoria revealed the conservation of all sites studied. The Cu^r genes cloned from P. syringae pv. tomato PT23 and X. campestris pv. vesicatoria XV10 did not hybridize to the Cu^r plasmids identified in the present study, indicating that copper resistance in these P. syringae pv. syringae strains may be conferred by a distinct genetic determinant.Peer reviewedPlant Patholog

ATP release from human airway epithelial cells studied using a capillary cell culture system

Epithelial release of adenosine triphosphate (ATP), an important autocrine and paracrine signalling molecule, is acutely mechanosensitive and therefore difficult to study. We describe here a novel preparation that minimizes mechanical and metabolic perturbations, and use it to examine ATP secretion by epithelial cells. The Calu-3 cell line derived from human airway sub-mucosal glands was cultured in a hollow fibre bioreactor on porous capillaries that were perfused by a re-circulating medium pump. Cells became polarized and cultures were stable for > 5 months, as evidenced by microscopy and lactate production (≈250 μg (108 cells)−1 day−1). Elevating apical flow rate 5-fold increased ATP secretion from ≈200 to 6618 fmol min−1. Reducing apical osmolarity by 25–43 % also increased ATP secretion, which then declined spontaneously to a plateau rate that persisted as long as hypotonic perfusion was maintained. Release deactivated rapidly after shear and osmotic stresses were terminated, and was not associated with detectable cell lysis. Lowering apical [Ca2+] to increase connexin hemichannel permeability also stimulated ATP release and increased secretion during both hyposmotic and shear stress; however, the connexin 43 blocker flufenamic acid inhibited shear-induced ATP release only in low-Ca2+ solution, and therefore another secretory pathway may operate with physiological (i.e. mm) calcium. Regardless of the mechanism, the present results quantify ATP responses to mechanical and osmotic stimuli and demonstrate the usefulness of capillary cultures for studying epithelial secretion