A pharmacists mom's experience with the health care system

1. A Pharmacist Mom’s
Experience with the
Health Care System
Allison Wells BSP, ACPR
PAS Annual Conference
May 1, 2016

2. Presenter Disclosures
I have no current or past relationships with commercial entities

3. Learning Objectives
By the end of this presentation the pharmacy professional
will:
Gain insight into the ups and downs of dealing with the
medical system from the patient/family perspective
Review an order that led to a critical medication error with a
focus on the unique and important role we as pharmacists
and technicians must play in the safe provision of drug
therapy and patient care
Comtemplate how technology can improve patient safety
Be prepared to Stop the Line the next time she sees a
potential for patient harm

4. Show of Hands
Who in the room is:
Pharmacist
Technician
Other health care professional
Community based
Hospital Based

5. Logan – Age 3

6. Our Story
Relatively uneventful pregnancy with nausea and vomiting until
approximately 17 week, diet controlled gestational diabetes and
some mild hypertension and edema requiring work restriction in
last trimester.
Logan was born August 15, 2010 weighing 8lbs 2 ozs
Concerns raised at 2 week appt but dismissed as new-mom
worry
Over next 4 months: Failure to Thrive, breast- feeding
difficulties, feeding 150ml/kg/day
Cloth diapered
Blood work on December 6  to ER

7. Our Story continued
Logan was feverish and vomiting throughout the night
Renal and Head Ultrasound normal
Transferred to Saskatoon under Endocrinologist for DI
workup after only 19 hours in Regina

8. Regina Labs
Lab Dec 6 @1925 Dec 7 @ 0117 Dec 7 @ 0740 Dec 7 @1205
Na (135-145) 165 167 171 170
K (3.5-5) 5.8 4.8 4.2 3.6
Cl (98-110) 130 135 137 139
CO2 (21-30) 21 22 28 27
Creatinine (60-130) 45 42 44 42
Urea (2-5.5) 7.4 5.9 4.8 3.9
Ca Cor (2.14-2.66) 2.73 2.74 2.71 2.62
Serum Osm (280-
305)
339 351 356 349
Urine Osm (300-900) 127 136
Treatment NS 48ml then
D5 ½ NS
@30ml/hr
NS 48ml then
continue with
same IV
Increase IV to
35ml/hr and start
DDVAP 0.25mg IV.
Replace urine +
15ml Q1H
Transfer to
Saskatoon
Urine Urine lytes
Na 41, K 12.1
u/o ~42ml/hr
(8.7ml/kg/hr)
u/o 49ml/hr
(10.1 ml/kg/hr)
u/o 75ml/hr
(15.5ml/kg/hr)

9. Graphic created by Tim Weakland, father to NDI child

10. Saskatoon Labs
Dec 7 Dec 8 Dec 9 Dec 10 Dec 11 Dec 12 Dec 13
Na 174 171 163 150 146 141 141
K 2.8 4.9 5.1 5.0 5.0 4.1 3.7
S Osm 332 333 311 309 296 295
Fluids D5 ½
NS @
2/3 1/3
with
20meq
KCl/L
½ NS ½ NS 1/3 NS
then
locked
U/O 1769 ml
(~14ml/kg
/hr)
1734 ml
(~14ml/kg
/hr)
1357ml
(~11
ml/kg/hr)
1211ml
(~9.5ml/k
g/hr)
801ml
(~6ml/kg/
hr)
634ml
(~5ml/kg/
hr)
539ml
(~4ml/kg/
hr)
Meds DDAVP 0.5
mcg SubQ
HCTZ
5mg po
Daily (1
mg/kg/day
)
HCTZ
5mg po
BID
(2mg/kg/d
ay)
HCTZ 10mg po BID
(4mg/kg/day)

11. Our Return Home
Feeding q1-2h
Drinking 2 liters a day
Vomiting, vomiting, vomiting
Non-stop sleep deprivation
Non-stop research and reading
LOTS of email contact with our
nephrologist, dietitian and
pharmacist

12. It’s the Little Things That
Matter -
True Patient Centered Care

13. May 2014 Admission

14. The Day I Saved My Son’s
Life…
or
…..the day our Health Care
System tried to kill my son

15. The Order
Na: 134, K 2.7 Age: 3.5 years old Weight:
11.9kg

16. Are we numb to potassium
orders? Would you have
caught the errors?
What is the maximum recommended dose of potassium
on a per kg basis in a 3.5 year old?
What is the maximum recommended rate of potassium
replacement in a 3.5 year old?
What is the maximum recommended concentration to be
administered peripherally?

17. Potassium Review
Dose
Usual dose is 0.5-1mEq/kg/dose. Logan’s was written as 1.7
meq/kg/dose.
Rate
Usual rate is 0.3mEq/kg/hr
“as ordered’ the rate should have been over 5.6 hours.
This is a 5.6 times rate error
Maximum rate is 1mEq/kg/hr
‘as ordered’ the rate could have gone as fast as 1.6 hours.
This is a 1.6 times rate error.
If infusion rate exceeds 0.5 mEq/kg/hr the patient should
have continuous ECG monitoring with physician at the
bedside.
Reference : Lexicomp

18. Potassium Review
Peripheral concentration
Logan received 40mEq/100ml solution
Usual concentration 20 mEq/L.
This is a 20 times concentration error.
Maximum peripheral concentration is 80 mEq/L.
This is a 5 times concentration error.
Dose should have been in the range of 6 mEq given over 2
hours to 12 mEq given 3.5 hours as 20mmol/L solution.
EVERY thing about this order was WRONG
and yet it reached a patient, my son.

19. Post-Scope

20. So why did this happen?
Multifactorial
Rushing to get scope done before GI retired
Logan had less sodium that day than usual due to being at daycare and
travelling unexpectedly to Saskatoon
Order for accurate ins/outs not initiated upon arrival to hospital
Resident unfamiliar with NDI
No nephrology officially on call
Iatrogenic lowering of potassium (2.7)
Anesthesia was not aware that Logan had NDI
OR was running early
Too many physicians (Resident, Nephrologist, Gastroenterologist,
Anesthetist)
No pharmacist check of order
Concentrated potassium available on the ward
Double check (high alert drug) done but unclear on what double check
all entailed for second signature by RN
Rushing, rushing, rushing!

21. What was done right?
We Stopped the Line right then!
Handled incredibly well by the entire team and health region
Apologies immediately
Internal meetings and changes the very next morning
Changes in solutions available on wards in following months
Changes in how potassium is ordered and given
Education of all parties
Follow up meetings with departments
Debrief with me!
Communication when errors occur is critically important
Helps with healing
Follow up counseling for Logan and for myself
Ongoing communication from the health region

22. Be the Change
https://youtu.be/pcQUnGiuhzM

23. It’s more than just
people:
Technology can make
our systems safer

24. Importance of Dose Error Reduction
System (DERS)
Prescribing 39% Transcribing 12% Dispensing 11% Administering 38%
Source of errors
Errors intercepted
48% 33% 33% 2%

25. Fictional Example
 As RN was in a hurry she
didn’t fax to pharmacy nor call
for a stat
 She found a “hidden” bag of
potassium 20 mmol/100mL
and decided to use it as she
was rushing to get child to
OR
 RN chooses a CCA based on
child’s weight
 Searches by POT
 Sees only 2 options, one
which is clearly labeled as
central line only
 In her haste she missed the
note about central line

26.  She enters the
parameters from the
order so she can give the
20 mmol over 30 minutes
as ordered

27.  The DERS ‘back-
calculates’ based on
the weight, duration
and VTBI
 It calculates a dose of
3.36 mmol/kg/hr
 A hard limit is reached
and she can not start
the pump until
parameters are
reprogrammed

28. What parents want you to
know
When the parents say "This thing about my child is
different than most kids", listen to them.
Little did we know, a few years later we would not only get
the NDI diagnosis but now our son would be permanently
catheterized at 7 years old because of all those Doctor's,
Specialists and Nurses who refused to listen.
I would ask them to do their due diligence when
confronted with a rare condition like NDI. A simple Google
search would provide them with some valuable info. Do
not assume your degree and education are enough -
please do some research. Even a Google search of
symptoms could yield crucial info.
Reference: NDI Facebook Page

29. What parents want you to
know
I would say if you do not know what a particular disorder
or disease is, please don't google it and then act like you
know what you're talking about. On multiple instances
they would talk to me about CDI, just admit you have no
clue. I respect you more for being honest and trying to
come to a solution with me, than to lie to me and pretend
like you know what you're talking about. Just because
you're a doctor doesn't mean I expect you to know.
Listen.
If a mother says NO have a bit of trust.
Not every patient is a horse. Some are zebras.
Reference: NDI Facebook Page

30. What I want you to know
LISTEN to patients and families when they tell you something is
wrong.
Pharmacists and technicians are integral to patient safety.
Optimizing therapy and being amazing clinicians means nothing if
patients do not receive the right drug, at the right dose, at the right
time. Safety happens at every stage in the drug distribution system.
Stop the Line
Even when it is hard, you must speak up for your patients every single
time. In our case seconds and minutes counted and there was no time
to completely review the situation appropriately before making a plan.
Stop the situation and fix it before proceeding. Our perfectionist
personas can’t get in the way of stopping unsafe situations.
My ultimate wish is the metamorphosis of health care into a truly
safe place for all our loved ones. One where the only worry parents
have during the admission of their child is loving and snuggling
them, not being on constant error watch. We have a long way to go
but we can all make changes every day to make this a reality.

31. Logan is alive because we
Stopped the Line

32. Thank you for listening to our
story