Medications Errors

Topic Areas media piece faced by a health care organization that is of interest to you.Create a 3-5-page annotated bibliography and summary based on your research related to best practices addressing one of the health care problems or issues in the Assessment
Introduction
In your professional life you will need to find credible evidence to support your decisions and your plans of action. You will want to keep abreast of best practices to help your organization adapt to the ever-changing health care environment. Being adept at research will help you find the information you need. For this assessment, you will review the Assessment Topic Areas media piece and select one of the health care problems or issues to research a current health care problem or issue faced by a health care organization that is of interest to you.

Demonstration of Proficiency
By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:
• Competency 1: Apply information literacy and library research skills to obtain scholarly information in the field of health care.
• Identify academic peer-reviewed journal articles relevant to a health care problem or issue and describe the criteria used for the literature search.
• Competency 2: Apply scholarly information through critical thinking to solve problems in the field of health care.
• Assess the credibility and relevance of information sources.
• Summarize what was learned from developing an annotated bibliography.
• Analyze academic peer-reviewed journal articles using the annotated bibliography organizational format.
• Competency 4: Communicate in a manner that is scholarly, professional, and respectful of the diversity, dignity, and integrity of others, and that is consistent with expectations for health care professionals.
• Summarize a health care problem or issue and describe a personal interest in it and experience with it.
• Write clearly and logically, with correct use of spelling, grammar, punctuation, and mechanics.
• Write following APA style for in-text citations, quotes, and references.

Instructions
Note: The requirements outlined below correspond to the grading criteria in the scoring guide. At a minimum, be sure to address each point. In addition, you are encouraged to review the performance level descriptions for each criterion to see how your work will be assessed.
For this assessment, you will research best practices related to a current health care problem. Your selected problem or issue will be utilized again in Assessment 3. To explore your chosen topic, you should use the first two steps of the Socratic Problem-Solving Approach to aid your critical thinking.
1. View the Assessment Topic Areas | Transcript media piece and select one of the health care problems or issues in the media piece to research. Write a brief overview of the selected topic. In your overview:
• Describe the health care problem or issue.
• Describe your interest in the topic.
• Describe any professional experience you have with this topic.
2. Conduct a search for scholarly or academic peer-reviewed literature related to the topic and describe the criteria you used to search for articles, including the names of the databases you used.
• You will want to access the applicable Undergraduate Library Research Guide related to your degree (found at the NHS Learner Success Lab) for tips to help you in your search.
• Use keywords related to the health care problem or issue you are researching to select relevant articles.
3. Assess the credibility of the information sources you find.
• Determine if the source is from an academic peer-reviewed journal.
• Determine if the publication is current.
• Determine if information in the academic peer-reviewed journal article is still relevant.
4. Select four current scholarly or academic peer-reviewed journal articles published during the past three to five years that relate to your topic.
5. Explain the relevance of the information sources.
• Describe how the health care problem or issue is addressed in each source.
• Discuss what kind of contribution each source provides on your selected topic.
6. Analyze the scholarly literature or academic peer-reviewed journal articles using the annotated bibliography organizational format.
• The purpose of an annotated bibliography is to document a list of references along with key information about each one. The detail about the reference is the annotation. Developing this annotated bibliography will create a foundation of knowledge about the selected topic.
• List the full reference for the source in APA format (author, date, title, publisher, et cetera) and use APA format for the annotated bibliography.
• Make sure the references are listed in alphabetical order, are double-spaced, and use hanging indents.
• Follow the reference with the annotation.
7. In your annotation:
• Identify the purpose of the article.
• Summarize the source:
 What are the main arguments?
 What topics are covered?
• Include the conclusions and findings of the article.
• Write your annotation in a paragraph form. The annotation should be approximately 150 words (1 to 3 paragraphs) in length.
8. In a separate paragraph or two at the end of the paper, summarize what you learned from your research.
• List the main points you learned from your research.
• Summarize the main contributions of the sources you chose and how they enhanced your knowledge about the topic.
Example Assessment: You may use the following to give you an idea of what a Proficient or higher rating on the scoring guide would look like:
• Assessment 2 Example [PDF].
Additional Requirements
1. Length: At least 3–5 typed, double-spaced pages, not including the title page and reference page.
2. Font and font size: Times New Roman, 12 point.
3. APA Template: Use the APA template linked in the resources. Use the APA Style Paper Template [DOCX] as the paper format and the APA Style Paper Tutorial [DOCX] for guidance.
4. Written communication: Write clearly and logically, with correct use of spelling, grammar, punctuation, and mechanics.
5. Content: Provide a title page and reference page following APA style.
6. References: Use at least four scholarly or academic peer-reviewed journal articles.
7. APA format: Follow current APA guidelines for in-text citation of outside sources in the body of your paper and also on the reference page.

This is the Paper Topic!!!
Medication Errors
Short Description:
A medication error is a preventable adverse effect of a patient taking the wrong medication or dosage, whether or not it is evident or harmful to the patient. Medication errors can be a source of serious patient harm, including death.
Potential Intervention Approaches:
• Medical staff education
• Packaging improvements
• Patient medication safety training
Keywords for Articles:
medication administration, medication errors, medication safety

Medication errors with push dose pressors in the emergency department and intensive care units
Acquisto, Nicole M; Bodkin, Ryan P; Johnstone, Christine.The American Journal of Emergency Medicine; Philadelphia Vol. 35, Iss. 12,  (2017): 1964-1965.

Here is the journal #1

Dear Reader,
Utilization of push dose pressors (PDP, low doses of phenylephrine or epinephrine administered IV push) during care of emergency medicine (EM) patients is increasingly popular in EM free open access medical education (FOAMed) [1,2] with resultant increased use in emergency department (ED) and intensive care unit (ICU) settings for peri-/post-intubation hypotension [3]. Due to prominence of this topic in FOAMed, indications are expanding to include bridge to continuous infusion vasopressors, medication related hypotension during procedural sedation and anaphylaxis.
This indication creep has potential detrimental effects, which are rarely discussed. Concerns we have identified are:
Differences in patient populations regarding cause of hypotension
Decreased considerations for usual management of disease, hypotension and expected medication related adverse effects
PDP preparation during acute patient management and dose errors
We report PDP errors with phenylephrine and epinephrine at our institution. The first case, a post-surgical patient with known blood loss/hypovolemic shock, developed hypotension during transport. Optimization of medications the patient was receiving (midazolam, fentanyl, hydromorphone) along with fluid resuscitation was not implemented initially. Phenylephrine PDP and propofol were used instead to treat hypotension and resultant hypertension. At presentation to the ICU, phenylephrine “50” was ordered and 50mg (50mg/5mL vials available in the ICU for continuous infusion admixing) was administered instead of intended 50μg. The second case, a post-laminectomy patient recently receiving norepinephrine continuous infusion for hemodynamic support, developed atrial fibrillation with rapid ventricular rate and was treated with diltiazem IV boluses/continuous infusion. The patient developed asymptomatic hypotension and phenylephrine PDP was ordered instead of fluid resuscitation/restarting norepinephrine (still at bedside) resulting in the entire phenylephrine pre-mixed syringe being administered by a physician, 1000μg [1000μg/10mL], instead of intended 100μg. Epinephrine errors occurred with 0.3 and 1mg administered IV for angioedema and allergic reaction (neither patient received intramuscular epinephrine) and 0.1 (100μg), 0.3, 0.5, and 1mg IV administered to patients for hypotension instead of intended 5-20μg. Adverse effects in phenylephrine and epinephrine cases were transient blood pressure elevations (>300mm Hg), ST depressions, and QTc prolongation. These cases highlight our concerns using PDP in ED/ICU settings. In the phenylephrine cases, it appears that PDP were the first resuscitation measure instead of fluid/blood administration. Also, better understanding of pharmacokinetics, adverse drug effects, and optimization of other medications the patient was receiving may have changed decision-making and prevented PDP administration.
FOAMed videos describe preparation of epinephrine PDP using cardiac arrest epinephrine syringes [1], however in acute stressful situations there is confusion regarding preparation and dose [4]. Since recent FOAMed discussions and recommendations for IV epinephrine for anaphylaxis [2] there are more errors related to this indication at our institution. Other near miss errors that we have encountered are physicians asking for epinephrine mixed to 100μg/mL concentration (misinterpretation of the 5-20μg dose vs. phenylephrine 100μg) and nurses asking to give 0.3mg doses IV since the patient has IV access. It seems that first line therapy with IM epinephrine for anaphylaxis and initiation of fluids/norepinephrine for hypotension is not being considered.
Furthermore, EM/ICU physicians are not traditionally trained in medication manipulation. Phenylephrine (available 1mg/mL) and epinephrine (available 1mg/mL, 0.1mg/mL) causes confusion regarding the number of dilutions to achieve the recommended μg/mL concentration and dose. A proposed benefit of PDP is availability at bedside, but we feel the time taken to manipulate these concentrations to provide small doses of vasopressor actually take the same amount of time as admixing and initiating continuous infusion vasopressor. In some situations (e.g. peri-intubation period) hypotension can be anticipated and having continuous infusion vasopressor ready at bedside would be a safer alternative due to increased familiarity. Some may argue that having pre-filled PDP syringes available may alleviate this confusion, however in one case we describe a ten-fold medication error with pre-filled phenylephrine syringes.
There are limited data regarding PDP use and safety in the ED/ICU. An evaluation of phenylephrine PDP for peri-intubation hypotension in the ED found use was not systematic and 70% of patients were also treated with continuous infusion vasopressor [3]. Author’s conclude PDP are used as a “bridge to vasopressor infusion or aggressive fluid resuscitation” which we would argue should be first line treatment. They infer that non-systematic use of phenylephrine may cause inadvertent negative effects for undifferentiated hypotension due to worsening shock secondary to inadequate fluid resuscitation. Although significant adverse effects were not seen in our patients past 1 h, there are several reports of epinephrine IV errors ranging from 0.04 to 1mg with significant adverse effects (intracerebral bleed, myocardial ischemia/infarction and dysrhythmias) [5-10]. There has been overwhelming positive support through FOAMed for PDP, but we believe it is important to present an opposing discussion regarding medication errors, patient safety, and potential risk.
References
1 S. Weingart, EMCrit Podcast 6 – push-dose pressors, Available at:, July 10, 2009
2 Emergency Medicine: Reviews and Perspectives (EMRAP). The doc in the bay: underutilizing epi in anaphylaxis, Vol. 15 (12), December 2015, Available at:, www.emrap.org
3 A.R. Panchal, A. Satyanarayan, J.D. Bahadir, D. Hays, J. Mosier, Efficacy of bolus-dose phenylephrine for peri-intubation hypotension, J Emerg Med, Vol. 49, 2015, 488-494
4 Emergency Medicine: Reviews and Perspectives (EMRAP). Strayerisms: anaphylaxis rebuttal, Vol. 16 (5), May 2016, Available at:, www.emrap.org
5 M. Kanwar, C.B. Irvin, J.J. Frank, K. Webber, H. Rosman, Confusion about epinephrine dosing leading to iatrogenic overdose: a life-threatening problem with a potential solution, Ann Emerg Med, Vol. 55, 2010, 341-344
6 J. Anchor, R.A. Settipane, Appropriate use of epinephrine in anaphylaxis, Am J Emerg Med, Vol. 22, 2004, 488-490
7 R.L. Campbell, F. Bellolio, B.D. Knutson, Epinephrine in anaphylaxis: higher risk of cardiovascular complications and overdose after administration of intravenous bolus epinephrine compared with intramuscular epinephrine, J Allergy Clin Immunol Pract, Vol. 3, 2015, 76-80
8 K.J. Shaver, C. Adams, S.J. Weiss, Acute myocardial infarction after administration of low-dose intravenous ephinephrine for anaphylaxis, CEJM, Vol. 8, 2006, 289-294
9 J.S. Park, J.H. Min, Y.N. In, Acute myocardial infarction due to stent thrombosis after administration of intravenous epinephrine for anaphylaxis, Chin Med J (Engl), Vol. 128, 2015, 2692-2693
10 G. Khoueiry, N.A. Rafeh, B. Azab, Reverse takotsubo cardiomyopathy in the setting of anaphylaxis treated with high dose intravenous epinephrine, J Emerg Med, Vol. 44, 2013, 96-99
Word count: 1021
Copyright Elsevier Limited 2017
Journal #2
Clinical pharmacy services in the emergency department
Sofie Rahman Morgan; Acquisto, Nicole M; Coralic, Zlatan; Basalyga, Vicki; Campbell, Matthew; et al.The American Journal of Emergency Medicine; Philadelphia Vol. 36, Iss. 10,  (Oct 2018): 1727-1732.

1 Background
1.1 Need for emergency medicine clinical pharmacists
Emergency medicine (EM) is a complex field. It demands management of diverse patient populations and medical problems that call upon a variety of clinical disciplines—from pediatrics to geriatrics and primary care to critical care. Utilization of time-sensitive and high-risk medications is common in the emergency department (ED). These complexities place the ED among the most high-risk patient care environments [1]. Including EM clinical pharmacists in treatment decisions and in implementation of therapy mitigates some of the risk and decreases medication errors [2-7]. EM clinical pharmacist services complement existing interprofessional teams of physicians, advanced practice providers, nurses, respiratory therapists, and prehospital providers.
Historically, hospital pharmacists focused on distributive functions (e.g., medication procurement, preparation, and delivery to the patient bedside). Today’s clinical pharmacists focus on patient care that optimizes medication therapy and thereby promotes health, wellness, and disease prevention. Clinical pharmacists provide expertise in the therapeutic use of medications and assume responsibility and accountability for managing therapy in direct patient care settings while collaborating with other healthcare professionals [8]. Their contributions to patient care and improved outcomes have been well documented and include reductions in patient mortality, hospital readmission rates, and medication errors [2,4,5,9-12]. They have also been shown to be highly valued team members in an EM environment [13,14].
1.2 History of emergency medicine clinical pharmacists
The introduction of clinical pharmacists in the ED was first reported in the 1970s [15-17]. Initial publications described their role in terms of medication distribution but also noted the provision of cognitive and consultative services based on the EM clinical pharmacist’s unique knowledge of pharmacology and therapeutics. In the first physician survey of EM clinical pharmacist services in a single center study, all respondents (physician and nurses) supported the EM clinical pharmacist as an integral team member, and 87% supported pharmacist delivery of care to certain patients after physician diagnosis [15]. In medical resuscitations, the role of the pharmacist included recognition as a drug therapy consultant for clinicians [18].
In more recent years, the role of the EM clinical pharmacist has expanded to include an increasing emphasis on comprehensive direct patient care services. Such services are centered on bedside patient assessment with the EM medical team and timely provision of patient-specific and disease-specific pharmacotherapy recommendations. EM clinical pharmacists aid in medication selection, optimal dosing and delivery, provision of drug information to patients and the interprofessional medical team, research and scholarly activities, and administrative and operational responsibilities to optimize the efficiency of care delivered to ED patients [19].
In 2005, the Agency of Healthcare Research and Quality (AHRQ) funded a project titled “Emergency Department Pharmacist as a Safety Measure in Emergency Medicine” (HS015818). The goal was to optimize the role of the EM clinical pharmacist and to develop a toolkit to aid institutions in the justification and creation of EM pharmacy services. This program, related publications from the grant, and an offshoot mentorship program [20] ultimately increased the national visibility and understanding of the value clinical pharmacists present in the ED, and this has contributed to the rapid expansion of their services over the past decade [13,21-23].
1.3 Non-pharmacist organizational support
In December 2013, the American Society of Health-System Pharmacists (ASHP) Section of Clinical Specialists and Scientists Advisory Group on Emergency Care (SAG EC) began drafting an American College of Emergency Physicians (ACEP) resolution to recognize EM clinical pharmacists as valuable members of the interdisciplinary EM team and to create a policy statement supporting clinical pharmacy services in the ED. The SAG EC is a volunteer group of practicing EM clinical pharmacists whose responsibilities include advancement of EM pharmacy practice and creation of educational content [24]. In October 2014, SAG EC and the American College of Clinical Pharmacy, Emergency Medicine Practice and Research Network (ACCP EMED PRN), in collaboration with and support of the ACEP’s New York Chapter, submitted resolution 44 (14) to the ACEP Council. Titled “Support for Clinical Pharmacists as Part of the Emergency Medicine Team,” the resolution was adopted with strong support after a presentation to the ACEP Council Reference Committee. A formal policy statement followed in June 2015 [25]. It represented the first time that ACEP formally recognized the critical role EM clinical pharmacists play in ensuring efficient, safe, and effective medication use in the ED and advocated for dedicated clinical pharmacists within the ED.
Furthermore in October 2017, the American College of Medical Toxicology (ACMT) published a statement that clinical pharmacists are integral to the care and safety of adult and pediatric ED patients [26]. The organization highlights the benefits of EM clinical pharmacists in time dependent emergencies, optimization of pharmacotherapy, safety, and cost avoidance and supports 24-hour staffing of dedicated EM clinical pharmacists in EDs.
One additional mention is that clinical pharmacists have been elected to leadership positions in interprofessional societies that relate to EM such as the American College of Toxicology and the Society of Critical Care Medicine.
2 Current state assessment
2.1 Current roles and responsibilities
EM clinical pharmacists play a variety of roles in practice sites, ranging from large academic and community centers to small and rural EDs. An updated guideline for EM pharmacist services published in 2011 defined the role of the clinical pharmacist in the ED, suggested goals for pharmacy services to meet institutional needs, and established best practices [27]. Activities of EM clinical pharmacists have most recently been summarized by a 2015 national survey study [19]. An extensive list is available in Table 1. Fig. 1 introduces a conceptual model of integration of EM clinical pharmacists into ED patient care and maps these activities in relation to ED patient flow; the majority take place at or near the bedside and involve face-to-face discussions with patients, physicians, nurses, and other team members.
2.2 Emergency medicine clinical pharmacy programs
The benefits of EM clinical pharmacists has received international recognition (e.g., Canada, Spain, United Kingdom, France, Qatar, Australia) [29-34]. In the United States, EM clinical pharmacy programs have shown marked growth over the last 15years. A 2003 national survey of the ASHP pharmacy residency directory reported that only 3.4% (4/119 respondents) had dedicated pharmacists assigned to the ED, and 10.9% had pharmacists whose primary responsibility was to provide pharmacy services to the ED [35]. A similar study conducted 10years later found that 16.4% (68/414 respondents) reported dedicated EM clinical pharmacists within the ED [36]. Likewise, a 2006–07 survey of 99 EM physician residency programs reported that 30% of respondents had dedicated EM pharmacists within the ED [23].
The most recent national survey of clinical pharmacy practice in ED settings took place in January 2015. It received a total 233 responses (58% response rate) [19]. Over two thirds of institutions (68%) reported more than 8h of dedicated pharmacist coverage during weekdays, nearly half (49%) reported more than 8h on the weekends, and most provided swing (1300−0000) or midday (0900–1900) coverage to focus on the high volume of patients during such hours [19]. Additionally, almost 10% of institutions reported 24-hour coverage on weekdays and weekends [19].
2.3 Training opportunities
As pharmacists expand from distributive functions to more direct patient care roles, educational and training requirements have increased. Beyond a professional doctorate degree, pharmacists are increasingly obtaining advanced certifications that reflect detailed knowledge in an array of specialties, receiving board certification through the Board of Pharmacy Specialties accrediting body, and completing general and specialty post-graduate residency training [37,38]. Post-graduate residency addresses the need for cognitive and skill-based training unique to the field and environment of emergency medicine (e.g., knowledge of a broad range of diseases and treatments, understanding ED workflow and practices, proficiency in working with the interdisciplinary ED team, execution of time-sensitive medication tasks like rapid medication preparation, comprehension of ED-specific treatment goals).
The first residency programs specific to emergency medicine pharmacy (Postgraduate Year Two, PGY2) emerged in the early 2000s, and a total of three programs were accredited by 2007. Less than ten years later, the number had increased tenfold. By 2016, there were 36 ASHP-accredited PGY2 EM specialty pharmacy residency programs and by 2017 there were 46 programs and several more seeking accreditation status. Residency program fill rates were 100% and 98% in 2016 and 2017, respectively, highlighting continued interest in this specialty among pharmacy graduates [39]. Training for EM clinical pharmacy services is also occurring in Postgraduate Year One (PGY1) residency programs, which are traditionally non-specialized, and as electives in schools/colleges of pharmacy. A recent national survey of schools/colleges of pharmacy and PGY1 residency programs reported EM pharmacy clinical rotation opportunities at 83% and 74.1% of responding programs, respectively [40].
Growth in clinical pharmacists working in the ED has nonetheless outpaced the number of PGY2 EM Specialty Pharmacy Residencies. This has given rise to alternative pathways to training. Some EM pharmacy programs now include an extensive orientation that entails shadowing clinical staff within the ED, understanding the job description of the EM clinical pharmacist, reviewing the services of the role, integration into daily operations using ED specific information and clinical topics, pharmacy operations, and hospital policies [41]. In 2007, ASHP developed the “Patient Care Impact Program (PCIP): Introducing an Emergency Pharmacist to Your Institution,” which provided experiential training and mentorship by EM clinical pharmacy specialists and an EM physician during initiation of EM clinical pharmacy services [20]. Over 80 participants have completed this program [42].
3 Supporting research
Reports of improved clinical, safety, and financial outcomes in EDs with EM clinical pharmacy services abound. A selection of various publications is discussed below.
3.1 Clinical and consultative services
EM clinical pharmacists play an essential role in improving the clinical care provided in EDs, as highlighted in Table 2. The results document improvement in areas such as disease-state specific outcomes measures, compliance with organizational and national clinical practice guidelines, medication use evaluations, ED or hospital readmissions, and antimicrobial stewardship.
3.2 Medication safety
Medication errors are common in EDs and may arise during clinical decision-making, prescribing, transcribing, dispensing, or administration of medications [2]. Including clinical pharmacists on the ED team leads to increased error interception and fewer medication errors. ED pharmacists are well equipped to correct the majority of prescription-related errors, especially those containing multiple medication orders and those prescribed by EM residents [3]. A prospective multicenter study of four geographically diverse academic and community EDs found EM pharmacists caught 364 medication errors during a 1000-hour study period [4]. Most errors were identified during consultative activities and review of medication orders. Improper dosing proved to be the most common type of error corrected [4]. Another prospective multicenter observational study found EM pharmacists caught 504 medication errors during an 800-hour study period [5]. The most common were incorrect dosing, drug omission, and incorrect frequency—alarmingly, almost half (47.8%) of intercepted errors were scored as serious for having potential to cause organ injury or alter life function [5]. Additional prospective studies in United States and Canada have also demonstrated EM pharmacists intercept and significantly decrease medication errors [2,3,5]. Retrospective studies have likewise shown EM pharmacists decrease medication errors [6,7] and increase medication error surveillance and reporting [56].
Medication errors are clinically significant, though many such errors do not result in harm to the patient; those that result in harm are referred to as adverse drug events [1]. Although it is clear that the presence of a pharmacist reduces the occurrence of medication errors, more research is needed to determine whether this results in a clinically significant reduction in clinically significant adverse drug events (ADE). To this end, we encourage rigorous evaluations of outcomes to fully describe the impact of EM clinical pharmacist practice.
Medication errors remain the most common error in medicine. Some result in no patient harm while others can be devastating and costly [1]. Adding EM pharmacists to the ED has shown to increase identification, interception, and correction of many medication errors, including some that may cause permanent patient harm or death. Additionally, EM clinical pharmacists have contributed to significant increases in medication error event reporting which is necessary for systems optimization to reduce patient morbidity and mortality from medication errors [58].
3.3 Financial implications
Allocating pharmacists to the ED requires balancing the desire to improve emergency care with the availability of health system resources. Research shows improvements in cost efficiency resulting from reductions in adverse drug events, adherence to evidence-based guidelines, timely implementation of medication therapies, and increased use of cost-effective drug therapies. A selection of cost-avoidance data is listed in Table 3.
Pharmacy departments generally fund EM clinical pharmacists, but some EM departments, physician groups, and schools/colleges of pharmacy contribute partial funding [19]. Other organizations reallocate pharmacists to the ED after evaluating clinical priorities for the health system [59]. Part of the AHRQ grant cited earlier was to develop a justification toolkit for EM clinical pharmacy services in the ED. This web-based resource (available at http://www.ashp.org/emergencycare.aspx) includes a selection of literature on clinical and safety outcomes.
4 Barriers to implementation
As with any new program or service, there are practical challenges to starting a dedicated EM pharmacist role. Common obstacles include approval and funding support by hospital leadership, staffing beyond traditional business hours, obtaining needed clinical support staff, defining the role of EM pharmacist, and altering the workflow of the ED to include the pharmacist [20]. For many institutions, the largest initial barrier may be the financial cost of including a pharmacist in the ED.
EM clinical pharmacists may seem an expensive resource [19]. The average annual salary for hospital-based pharmacists in the United States is around $120,000 [62]. Because EM clinical pharmacists do not provide a direct source of revenue, it is imperative for EM physicians and administrators alike to value the many quality and efficiency benefits (and related savings) that EM clinical pharmacists provide.
The studies noted above lead us to firmly believe that the cost of adding dedicated clinical pharmacists to the ED is more than offset by increases in patient safety (and savings) that their presence brings about. As value-based reimbursement and new payment models focus less on service quantity, the safety and efficiency value of the pharmacist relative to salary cost may further increase.
5 Limitations
The primary literature cited does not reflect the entire body of published literature relating to EM clinical pharmacists. Instead, the authors chose to intentionally highlight key literature citations that focus on the history of EM clinical pharmacists and how pharmacist involvement in the interdisciplinary team impacts outcomes, safety, and cost. Also, tertiary literature and research abstracts from professional society meetings were not reviewed. The goal was a general overview of EM clinical pharmacy programs, not a formal systematic review. In this respect, exclusive use of electronic indexing databases without a predefined search strategy may have potentially resulted in the omission of additional relevant literature.
Much of the available literature on EM clinical pharmacists is from observational reports and surveys of current practices. Clinical outcomes data has become more prevalent with the significant growth in EM clinical pharmacist presence over the last 10years. Although we have been unable to locate any randomized controlled trials of EM clinical pharmacists, several clinical outcomes data and disease-specific management studies describe improved outcomes associated with EM pharmacist involvement (Table 2). Additionally, the majority of the observational studies available have evaluated surrogate markers of safety and efficiency but have not consistently evaluated the full and direct impact on clinically significant outcome measures. As we encourage growth in dedicated EM clinical pharmacist roles, we challenge new and existing programs to evaluate these clinically significant outcome measures to further contribute to this body of knowledge.
6 Conclusion
Growth in EM clinical pharmacist presence in EDs represents an important advancement in patient care. With numerous studies demonstrating a positive impact on quality and efficiency of care, EM clinical pharmacists should be viewed as an essential member of an effective and efficient emergency medicine practice. While the specific roles of an EM clinical pharmacist may vary based on institutional needs and resources, all health systems should consider ways to support a dedicated EM clinical pharmacist or EM pharmacy residency training program.
Source of support
None.
Prior presentations
None.
Acknowledgements
The authors would like to acknowledge the following people for their invaluable contributions to this paper: Rollin J. (Terry) Fairbanks, MD, MS; Dickson Cheung, MD; David Nestler, MD, MS; Sam Torbati, MD; Benjamin White, MD; Stephen Cantrill, MD; Alex Morgan, JD; Margaret Montgomery, RN, MSN; Julie Wassom; and the ACEP Emergency Medicine Practice Committee. We also thank the following organizations for their support of EM clinical pharmacists: American College of Emergency Physicians, American College of Medical Toxicology, American Society of Health-System Pharmacists, American College of Clinical Pharmacy, Agency of Healthcare Research and Quality, and the Emergency Nurses Association.
Conflict of interest disclosure
SM, NA, ZC, VB, MC, JK, KL, CP, MP, ES report no conflicts of interest.
Bedside clinical activities
●Emergency department resuscitation team (cardiopulmonary arrest, trauma and burn resuscitation, myocardial infarction
, stroke, sepsis)●Direct bedside care during high risk medication use (rapid sequence intubation, procedural sedation)●Pharmacotherapy consultation○Drug information○Medication selection○Medication dose
(based on patient specific factors; age, weight, route of administration, renal function)○Medication therapy monitoring
●Drug interaction analysis●Drug identification●Drug compatibility for admixing or administration●Error and adverse event reporting●Patient counseling and education●Toxicology recommendations●Targeted disease state counseling
(e.g., anticoagulation, anaphylaxis)●Antimicrobial stewardship activities including microbiological culture and susceptibility follow-up●Prospective medication order review and verification●Assistance with medication procurement/preparation
(advanced knowledge of medication storage and distribution and institutional policies and procedures)●Medication administration●Vaccine administration●Emergency preparedness●Facilitation of medication histories
●Oversight of pharmacist extenders (e.g., technicians, students)
Training and education
●Medication therapy updates and education on optimal medication therapy for ED team members
(often takes place at the bedside or in the ED)●Education through conference and pharmacology rotations for
EM attendings and residents●Implementation and execution of post-graduate EM pharmacy residency training programs
●Participation in interdisciplinary simulation
Performance improvement
●Guideline/protocol/process development●Formulary management●Medication dispensing cabinet optimization
●Optimization of medication procurement workflows●Medication safety initiatives●Participation in root cause analysis
(RCA) and failure mode and effects analysis (FMEA)●Assistance with adherence to regulatory and institutional
medication use policies
Scholarly activities
●Interdisciplinary EM clinical research●Identification of patients for enrollment of investigational drug studies recruiting in the ED●Participation in interdisciplinary research committees that review ED related research protocols
●EM related research grant preparation●EM medical resident research projects or quality improvement projects
●Participation in articles, book chapters, case reports, or other collaborations with EM physicians

Journal #3
Push dose pressors: Experience in critically ill patients outside of the operating room

1 Introduction
Peripheral push dose vasopressors (“push dose pressors”, PDP) have gained widespread use in an array of medical settings and are commonly used in operating rooms (OR) for peri-intubation hypotension. Outside the OR, PDP are used less often but are becoming increasingly more frequent for peri-intubation hypotension, as a bridge to continuous infusion vasopressors and for medication related hypotension during procedural sedation and anaphylaxis despite limited studies [1-4].
In November 2015, we developed and implemented a PDP guideline with restricted use for critically ill patients with limited indications including: transient hypotension in the setting of post-intubation or procedural sedation, as a bridge to continuous vasopressor infusion, and for emergent transport in an unstable patient without time to begin a vasopressor continuous infusion. Two PDP options were made available, phenylephrine with alpha-1 receptor activity only and ephedrine with both alpha-1 receptor and beta-1 receptor activity, for provider preference. Phenylephrine bolus doses from 50 to 200 μg and ephedrine bolus doses from 5 to 25 mg administered every 2–5 min were recommended for physician administration only and pre-filled diluted phenylephrine (1000 μg/10 mL) and ephedrine (50 mg/10 mL) syringes were made available in the medical, surgical, neuromedical and burn/trauma intensive care units (ICU). Recommended doses were translated from previous OR data [5-7]. The emergency department was not included in this practice change for concern of medication errors and adverse effects with high-risk medications in a vulnerable practice setting (pre-made continuous infusion vasopressors are readily available).
The purpose of this study was to perform a medication use analysis evaluating PDP practice patterns in critically ill patients in non-OR settings throughout the hospital. We sought to characterize overall use, determine efficacy, and identify adverse drug events or medication-related safety concerns.
2 Materials and methods
2.1 Study design
This was a retrospective, observational analysis of hypotensive adult patients that received a PDP in a clinical area outside of the OR at an urban university tertiary care hospital. Approval for this study was obtained from the university’s institutional review board.
2.2 Study setting and population
This study was conducted at an 850-bed university teaching hospital with 74 relevant adult intensive care unit beds. Data was collected from November 2015 through March 2017. Patients were captured from the electronic medical record through medication orders of phenylephrine 1000 μg/10 mL or ephedrine 50 mg/10 mL syringes. All patients 18 years of age and older who received at least one phenylephrine or ephedrine PDP were included. Patients receiving phenylephrine for priapism or a PDP in the post anesthesia care unit were excluded. Any patient that did not have a particular vital sign (systolic blood pressure [SBP], diastolic blood pressure [DBP], or heart rate [HR]) available before and after PDP or were determined to have a dose related medication error were excluded from the efficacy analysis.
Any patient with unclear dosing documentation (documentation in the medication administration record did not match the nursing notes) were excluded from dose description and dose related medication error evaluation, but were included in the safety evaluation.
2.3 Study protocol
Three abstractors conducted a complete medical record review using a standardized data collection tool and data dictionary. Education sessions regarding data collection to ensure that data was extracted in the same way were completed with the two of the investigators. Patients may receive PDP at different times during their hospitalization, and as such we sought to capture these as discrete events. Each PDP “event” was defined as PDP administration occurring within a 2-hour period. If a PDP was administered outside of this window then this was included as a separate event. Data collected included patient and service demographics, PDP administration details including medication, indication, dose, frequency, and total number of doses, vital signs pre- and post-administration, number of patients started on a continuous infusion vasopressor, incidence of crystalloid fluid prior to PDP administration, and adverse events and medication errors.
Systolic blood pressure and DBP from 30 min prior (using the lowest value if multiple readings) to administration and 30 min after administration (using the highest value if multiple readings) were collected. In some cases, subsequent administrations of PDPs altered the 30-minute time period and shorter pre- and post-timeframes were used.
Adverse effects including SBP > 200 mmHg or increase >100%, HR increase or decrease >30%, incidence of dysrhythmia (within 30min), ischemia (troponin elevation or myocardial infarction within 24 h), hypertension or reflex bradycardia requiring treatment were evaluated. Also, medication errors such as a single dose of phenylephrine >200 μg or ephedrine >25 mg, PDP administration to patients with a SBP > 100 mmHg or HR > 160 bpm, or PDP administration while already on a continuous infusion vasopressor were identified. Lastly, we evaluated how often PDPs were used in the peri-death period defined as <1 h before time of death to evaluate the frequency of survival versus death in these patients.
2.4 Data analysis
Descriptive statistics were used to characterize the study sample and current PDP practice. Patient demographics, medical service characteristics, and circumstances surrounding PDP administration were quantified by stratifying the sample in three groups: patients who received phenylephrine, patients who received ephedrine, and patients who received both medications. Efficacy was evaluated by describing the absolute and percent change.
Comparisons between groups were made using paired sample t-test, Wilcoxon rank sum, Chi-squared analysis, or Fisher’s Exact Test as appropriate. Efficacy metrics for vital signs were calculated by quantifying the mean value pre- and post-PDP administration and the mean change from baseline and percent change. Frequency of adverse effects was quantified using proportions. A p-value <0.05 was considered statistically significant for all analyses.
3 Results
During the study period there were 155 PDP events in 146 patients (mean age 64 ± 13.3 years and 66.4% were males). The most common admitting diagnosis was respiratory failure (39.8%) and most frequent vasopressor used was phenylephrine (104), although many patients did receive ephedrine (33), or both phenylephrine and ephedrine [9]. There were 116 PDP events where the doses administered were clear in the documentation. Of those, the mean phenylephrine and ephedrine dose were 147 ± 68.8 μg and 14.2 ± 8.5 mg, respectively. Most patients (75%) received one dose of PDP during an event, 19.8% required two and infrequently were three or more doses required (5.2%). One patient received five doses of PDP during an event.
Most patients received PDP in the peri-intubation period (57.3%) and the surgical ICU was the most common user of PDP followed by the medical ICU, contributing to 78% of use outside of the OR. Lastly, only 26.7% of patients received fluid administration in response to decreased blood pressure at the time of PDP. Complete demographics are available in Table 1. Fig. 1 describes the number of patients included in each efficacy and safety analysis.
3.1 Efficacy
We were able to assess efficacy based on pre- and post-PDP vital signs in almost 80 patients in each vital sign category (Table 2). The mean change in SBP was 26 mmHg (32.5% change from baseline), DBP was 13 mmHg (27.2% change from baseline), and HR was 6 beats per minute (6.4% change from baseline). Interestingly, mean HR increased more in the phenylephrine group (6.3%) than in the ephedrine group (3.5%). Overall 41 patients (28%) were started on a continuous infusion vasopressor after PDP (most often norepinephrine) and no patient died within an hour after PDP.
3.2 Safety
Table 3 describes all adverse events and medication errors. A total of 17/146 (11.6%) patients had an adverse event associated with PDP administration. Thirteen of 116 patients (11.2%, 116 had clear dose information, Fig. 1) had a dose related medication error (phenylephrine dose >200 μg or ephedrine dose >25 mg), nine (6.2%) received PDP with normal/elevated hemodynamics (systolic BP > 100 mmHg or HR > 160 bpm) and 15% while on a continuous infusion vasopressor.
4 Discussion
To our knowledge there are limited studies evaluating PDP usage patterns, efficacy, and safety outside of the OR [1-3]. Other reports and commentaries have been focused on medication safety and errors [4,8,9]. We sought to characterize PDP use in our critically ill population and also evaluate efficacy and safety. Overall, we found that phenylephrine is often used in the peri-intubation period, which is similar to previous reports of PDP use outside of the OR [1,2]. Selection of phenylephrine or ephedrine varied, but our surgical ICU had the highest percentage of ephedrine use likely due to comfort of anesthesia/critical care providers and familiarity with use compared to other critical care areas. Another interesting finding was that patients receiving phenylephrine required additional doses more often than ephedrine, which may be related to the shorter half-life.
As expected, PDP improved BP and HR, however it was surprising that phenylephrine, only having alpha-1 receptor activity had a greater HR increase than ephedrine. In our study, only 28% of patients were started on a continuous infusion vasopressor after PDP compared to 70% and 59% in other reports [1,2]. One explanation may be attributed to patient population differences; ICU compared to emergency department (ED). Specifically, it seems that PDP were being used to bridge to continuous infusion vasopressors in the ED studies, but this was not the intent of PDP use in the majority of our patients (temporary vasopressor support during transient hypotension). Also, continuous infusion vasopressors are pre-made and readily available at our institution in medication dispensing cabinets in high-use areas making this indication of bridging to infusion unnecessary. Furthermore, many of our patients that received PDP for transient hypotension were undergoing a procedure (e.g. bronchoscopy) where hemodynamic instability is expected to resolve after completion and therefore not require continuous infusion vasopressors. In no encounters were PDP used in the peri-death period. We cannot make any conclusions regarding the efficacy in improving patient condition, clinical outcome, or preventing death, but it seems that providers are not using PDP towards the end of resuscitative efforts.
It is important to highlight that there were adverse events and medication errors associated with PDP use in our study including one case of dysrhythmia. Most often these were significant changes or elevations in SBP or HR or inappropriate PDP doses administered. We did find over 10% of patients with a medication error related to high phenylephrine or ephedrine doses; >200 μg and >25 mg, respectively. We chose these dose thresholds based on previous OR data recommending bolus doses of phenylephrine of 100–150 μg or 1–2 μg/kg [5-7]. Swenson et al. described phenylephrine bolus doses ranging from 10 to 500 μg/dose for the first dose and correlated a greater mean arterial pressure (MAP) change in the 200–500 μg dose range compared to <200 μg; +12 vs. +4–5.6 mmHg, respectively [2]. As stated in the limitations of this study, much of the documentation was from handwritten resuscitation notes and subject to recording errors. From our experience, it is difficult to assume that, for example, 500 μg was administered as a single dose or as smaller, quickly titrated, doses and then the total dose documented, which could confound the interpretation of the MAP measurement results. Also, in this study, cases were excluded for incomplete pre- and post-blood pressure measurements but it does not seem any cases were excluded for dose documentation discrepancies between the nursing notes and medication administration record like we did in our study. When comparing our mean SBP and DBP, this would correlate to a calculated higher MAP difference than Swenson and colleagues showing potentially greater efficacy as far as hemodynamic changes at lower individual doses. Although we defined these dose thresholds from our institution guidelines and previous OR literature, these may not define the upper dosing limits at all institutions.
In our evaluation there were several cases of PDP administration during normal BP or elevated HR, administrations while a continuous infusion vasopressor was already infusing, and only a small amount of patients received crystalloid fluids around the time of PDP administration. Although we did not have any patients with a relative increase in troponin level from baseline following PDP, we did have several patients receive PDP with a pre-existing elevated troponin level, but no associated adverse effects were seen. It is difficult to determine the negative clinical effects or impact on outcome of these incidents since our overall patient sample was small.
Our overall rate of adverse events was 11.6% compared to 2.7% in previous studies, but this difference is likely due to our expanded definitions for adverse events which included a percent SBP, DBP, HR change, administration of PDP with normal vital signs, and administration during vasopressor continuous infusion [2]. Our guideline restricts administration to physicians which was an attempt to reduce overall inappropriate use, create familiarity with the multi-dose syringe, and minimize medication errors. It is difficult to infer if this approach had any effect on our adverse effects and medication errors rates as we do not have a comparator group.
There were several notable limitations for this study. This was a retrospective study with small sample size and thus our ability to control confounding factors was limited. Push dose pressor use is often during high-stress or fast-paced situations and as a result documentation was often incomplete or unclear for PDP administrations. We did attempt to clarify medication administration record documentation with nursing notes and excluded patients from certain analyses if documentation was unclear. As a result, however, this decreased our sample size, made it more difficult to identify medication errors, or correlate medication errors to negative effects or identify if treatment was administered in relation to an unwanted PDP effect or error. Real-time, individual bolus dose documentation with subsequent hemodynamic measurements between each dose would be beneficial to evaluate the efficacy of this approach. Use of the narrator function and technology integration for direct vital sign input into the electronic medical record without nursing transcription may improve documentation.
Most of the PDP use in our study was in the peri-intubation period, but we did not collect induction agent information. Medications used for induction may independently cause hypo- or hypertension which could have confounded our efficacy analysis. Study definitions for adverse events may have been too simplistic and there is the possibility that, for instance, a SBP increase by >100% may have been the goal for therapy even though our intent was to identify severe, unintended, derangements. Although we did not find an association with the lack of fluid administration, receiving a PDP while on a continuous infusion vasopressor, or PDP administration in a patient with an already elevated troponin and any adverse effects, this should be interpreted with caution as our sample size is small and there is the possibility of type II error. Lastly, there were no evaluations of clinical outcome, achievement of goal hemodynamics or a continuous infusion comparitor group. It is still unclear if there are any differences in outcomes with PDP administration compared to traditional continuous infusion vasopressor use. Also, long-term outcomes were not evaluated so it remains unclear if PDP have any influence on morbidity and mortality; however, this study provides needed data on use patterns, efficacy, and safety in the immediate post-administration period.
5 Conclusions
The study found that PDP were used in critically ill patients with a variety of diagnoses but experiencing similar and select clinical indications. Push dose pressors were shown to be efficacious regarding vital sign changes, but were also associated with adverse drug events and frequent medication errors. Additional studies need to be performed to evaluate the long-term clinical impact of PDP as well as to further examine adverse events and medication errors to better understand their overall impact on patient outcomes.
Acknowledgements
Frank Latucca, Pharm.D.
Matthew O’Connell, Pharm.D.
Christopher Nyiri, Pharm.D.
University of Rochester Medical Center, Department of Pharmacy.
Source of support
None.
Prior presentations
None.
Socratic Problem-Solving Approach
The Socratic Method is a teaching style in which teachers ask students questions designed to stimulate more complete thinking and deeper insight. It also relates to the steps of performing scientific research. When the Socratic approach is applied, students are prompted to look more closely at your ideas, question your assumptions and accepted premises, and view your choices through a rigorous lens.
Apply the Socratic approach
Applying the Socratic approach to problem solving helps you identify gaps and improve your thinking when writing papers or completing projects. The questions may be used to spark new insights when responding to discussion topics and posts.
• Identify the elements of the problem, issue, or question
Supporting actions:
•
• Break the problem down into pieces, elements, or components.
• Recognize how the pieces or components are related to each other.
• Look for missing information or gaps in what you know.
• Note the information that you do not have, cannot find, or is unavailable.
• Separate symptoms from underlying causes.
• Avoid judgments and premature solutions.
• Gather information.
Supporting questions:
• What problem am I trying to solve?
• What are the key issues in this problem?
• What facts do I have? A fact is “something that actually exists; reality; truth; a truth known by actual experience or observation; something known to be true.”*
• What evidence do I have? Evidence is “that which tends to prove or disprove something; grounds for belief; proof.”*
• Which pieces of information are opinions? Opinion is “a belief or judgment that rests on grounds insufficient to produce complete certainty; a personal view, attitude, or appraisal.”*
• Which pieces of information are inferences? To infer is “to derive by reasoning; conclude or judge from premises or evidence.”*
• Are the inferences well or poorly reasoned? Can alternative inferences be drawn from the same facts or observations?
• Which pieces of the information are theories? A theory is “a more or less verified or established explanation accounting for known facts or phenomena.”*
• What do I not know?
• What information is missing, and is it possible to get the information I do not have?
• What are the possible sources of information?
• What must remain unknown for now?
• Analyze, define, and frame the problem, issue, or question

•
Supporting actions:
•
• Gather information that you need to know more about the context surrounding this problem.
• Decide which pieces of information are important.
• Identify your point of view.
• Consider how your cultural values shape your perception of the problem.
• Evaluate conflicting evidence.
• Separate symptoms from underlying causes.
• Avoid value judgments and premature solutions.
• Analyze arguments.
• Identify what you do not understand and the complexities of the problem.
• Define a research problem.
Supporting questions:
• What are my goals? What am I trying to accomplish?
• Which pieces of information are the most important in relationship to this problem?
• Is the information, or presented evidence, relevant to the problem? Are there other ways to interpret the information?
• How does the information relate to:
1. What I already know?
2. My personal and professional experiences?
• How does this information support or match my experiences?
• How does it contradict or differ from my experiences?
• What information opposes my position?
• What theories in my discipline shed light on this problem?
• What are the values, beliefs, and assumptions (i.e. or the things that are taken for granted and usually unstated) implied in the problem statement?
• What are my values and beliefs in relationship to this problem?
• Am I ignoring evidence that does not fit with my beliefs?
• Am I failing to consider or investigate evidence that may contradict the theory I support?
• What are my assumptions in relationship to this problem?
• What support or evidence do I have to back up these assumptions?
• What are the values, beliefs, and assumptions of my sources of information and references in relationship to this problem?
• How does my culture or my world view shape my approach to this problem?
• How would someone from another culture or world view approach this problem?
• What are the possible causes of this problem?
• What blind spots are keeping me from seeing additional causes?
• What evidence supports my assertions? How reliable is this evidence?
• What evidence supports others’ assertions?
• How reliable is this evidence?
• What other issues relate to this problem?
• Am I considering the complexities of this problem?
• How important is the problem relative to other problems?
• Consider solutions, responses, or answers
•
Supporting actions:
•
• Consider the evidence for and against:
1. Your theory or viewpoint.
2. Others’ theories or viewpoints.
• Analyze arguments.
• Imagine the implications of each possible solution.
• Formulate research questions or hypotheses.
Supporting questions:
• What theories relate to these solutions?
• What are the possible expert views that may be held on this problem?
• Which views are best supported by evidence?
• What are all the possible solutions, resources, and constraints to this problem?
• Additional solutions
1. What blind spots are keeping me from seeing them?
2. What are the implications of these?
3. What might be the consequences of these?
4. What world view does each imply?
• Choose a solution, response, or answer

•
Supporting actions:
•
• Evaluate your choice from alternative viewpoints, or put yourself in someone else’s shoes.
• Question and consider the problems that may arise from your choice.
• Choose research questions or hypotheses.
Supporting questions:
• What theories in the discipline provide support for this solution?
• How did I reach this conclusion?
• Is this solution aligned with my goals? Does this solution address the problem’s most critical aspects?
• Why do I prefer this solution, response, or answer?
• How is this solution, response, or answer supported by, or dependent upon,:
1. Data, facts, and evidence?
2. Opinions or inferences?
• What are the costs of this solution?
• What are the possible risks of this solution? How likely are those risks?
• What are the possible benefits of this solution? How likely are those benefits?
• How do my biases affect my choice? What alternative biases might be held by others, and how would these affect their choices?
• What assumptions, values, and goals does my choice imply?
• Implement your choice

•
Supporting actions:
•
• Develop an action plan.
• Test research questions or hypotheses.
Supporting questions:
• Is the implementation supported by theory?
• Is the implementation supported by the facts?
• Is the implementation consistent with my purpose?
• Evaluate the results
Supporting actions:
• Analyze the results of your actions.
• Analyze research data and formulate new questions based on the results.
Supporting questions:
• Did I make progress toward solving the problem?
• What did I learn?
• How do the results relate to existing theories?
• How do the results shed light on the existing body of evidence?
• What new questions are raised by the results?