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Clinical Pharmacist Department of Pharmacy Southcoast Hospitals Group Charlton Memorial Hospital 363 Highland Avenue Fall River, Massachusetts 02720 fax 508/679-7329 zolnierzm{at}southcoast.org
Clinical Pharmacy Coordinator Department of Pharmacy Southcoast Hospitals Group Charlton Memorial Hospital
Director of Pharmacy Services Department of Pharmacy Southcoast Hospitals Group Charlton Memorial Hospital
Published Online, January 6, 2009. www.theannals.com, DOI 10.1345/aph.1K685b
Dosing of Intravenous Acetylcysteine. The authors correctly state the 3 doses for intravenous acetylcysteine in acetaminophen overdose that are in accordance with the Food and Drug Administration–approved manufacturer's recommendations.3 The oral loading dose of acetylcysteine is 140 mg/kg, followed by 70 mg/kg every 4 hours for 17 doses. In the article, the oral dose was used as the intravenous dose in 2 of the errors. The Excel program order sheet identifies all 3 intravenous acetylcysteine dosage regimens in milligrams per kilogram format followed by the equivalent volume of intravenous acetylcysteine in milliliters. The acetylcysteine dose is specific to the patient's body weight in kilograms entered into the program. This order sheet eliminates the need for locating intravenous acetylcysteine dosage charts and transferring that information onto a physician order form. Additionally, the space saved by not inserting dosage charts into the document allows for the insertion of an oral acetylcysteine section into the program printout.
Incorrect Rate of Acetylcysteine Infusion. This aspect of acetylcysteine infusion for the treatment of acetaminophen overdose can be confusing. Each section of the acetylcysteine regimen has a different diluent volume and administration time. The computer-generated order sheet lists each of the acetylcysteine dosing segments in a format that includes dose in milligrams per kilogram for that section, the required amount of acetylcysteine in milliliters, the amount of diluent, the total volume in milliliters of acetylcysteine and diluent, the flow rate in milliliters per hour, and the administration duration of this segment in hours. The printed flow rate reduces the likelihood of errors in the flow rate of acetylcysteine.
Interruption in Therapy Greater than One Hour. A simple and streamlined approach to generating the treatment order sheet helps to facilitate the use of the program. The nurse clicks on a computer screen icon, enters the patient's weight in kilograms, and then clicks a computer screen button. The patient weight–specific computer-generated physician order for acetylcysteine in treating acetaminophen overdose is automatically printed. The nurse affixes a barcoded patient identification label and scans the order sheet to send to the pharmacy department. Upon receiving the scanned physician order sheet, the pharmacist contacts the emergency department to determine which dosing regimen is being administered and when the next dose is required. The order sheet helps the nurse to readily identify the entire 3-dose regimen, working to ensure that all 3 doses are administered and the entire protocol is completed.
Since previous publication of our results,2 an additional 7 patients have received acetylcysteine for the treatment of acetaminophen overdose, resulting in a total of 14 patients treated with this program. All patients appear to have received the correct dose of acetylcysteine according to the medical record. It is hoped that the design of this program has minimized the occurrence of acetylcysteine medication errors. It is serendipitous that the Microsoft Excel computer program that is used in analyzing the errors is the same program that may prevent these same errors.
Footnotes
Comments on articles are submitted to the authors of those articles. When no reply is published, either the author chose not to respond or did not do so in a timely fashion. Comments and replies are not subject to peer review.–ED.
This information was presented at a poster session of the Massachusetts Hospital Pharmacy Association in March 2006.
Letters are subject to review prior to acceptance. They should address areas related to pharmacy practice, research, or education, or articles recently published. Corrections of previously published material also are accepted. Letters are limited to no more than five authors. In cases where adverse effects or drug interactions are described, the Naranjo ADR probability scale (Clin Pharmacol Ther 1981;30:239-45) or DIPS scale (Ann Pharmacother 2007;41:674-80. DOI 10.1345/aph.1H423), respectively, should be used to determine the likelihood that the adverse effect or interaction was drug-related.
References
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