2 responses for 2 discussion questions
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It is common practice in my ICU to stop all non-life sustaining medications. This seems practical at first given most of the medications we think of are doing the opposite of what we are trying to achieve (adequate blood pressure, protecting airway) but it also includes any psychiatric medications they were on. I spoke with two physicians in my practice and several charge nurses and they have seen the same thing repeated with the same results, longer stay in the ICU with a longer intubation time. In a study done by Gacouin et al., they found that psychiatric patient admitted for a self-harm event were more likely to survive their admission than their admission for medical reason counterparts (2017). Those with admission for chronic or acute medical needs were more difficult to treat and is thought to be associated with poor adherence to treatment required to stay healthy (Gacouin et al., 2017). Some common medications have been found to increase inflammatory responses so stopping those in many cases would be appropriate, however, not restarting them after the acute phase may cause setbacks in extubation.
To bring the problem to light I will explain a common scenario and the most extreme case I worked with: Patient comes in for respiratory failure and all medications are stopped. Patient is found to have sepsis due to pneumonia and it is now known they are on several psychiatric medications, but they are not restarted or even considered during rounds. Daily awakening trials take place with no success due to agitation. Patient then self-extubates and codes, we get the patient back. Spouse is also a psychiatric patient and has attempted suicide upon hearing of the changes. Patient remains a full code is on four pressers (that is the limit unless we get creative) and it looks grim. Patient rebounds, recovers enough to get a tracheostomy and feeding tube placed. The state designated crisis responder for this patient asks when the last dose of psychiatric medication was administered, it had never been restarted. Nearly 30 days into the stay home medications are restarted. Patient fully recovers but must do it in the hospital setting without formal rehabilitation, due to their psychiatric diagnosis on file no facility would accept the patient.
The quality of care in this case was lacking in respect to the patient and their full picture of health. Our facility ignored a significant diagnosis and it led to challenges that may have been avoided if we had continued to treat their chronic illness. This is not the first facility I have practiced in that employs this way of thinking, but it needs to change. Having a dedicated psychiatric practitioner available in the ICU would decrease these incidences and improve outcomes. This is not just a national problem but a global problem. In India they found on average 20%-60% of ICU patients have a psychiatric diagnosis and early identification along with early treatment resumption could lead to shorter stays and better outcomes (Nongmeikapam et al., 2018).
Participating in the collaborative interview was two staff nurses, a pharmacist, and a nursing administrator. It was discussed in the collaborative meeting that obtaining adverse drug event (ADE) data is challenging because of a lack of reporting. Current evidence suggests that only 5% of ADEs are reported in the clinical setting (Bailey et al., 2016). Both nursing and pharmacy participants reaffirmed that they believe ADEs are underreported through their practice. They informed that fear of being reprimanded, personal insecurity due to the error, time, workload, termination, and possible revoking of their licenses were core to not reporting ADEs.
Additionally, ADE reporting standardization and tools to report these events are lacking. Currently, the U.S. Food and Drug Administration tracks ADEs, which are relayed to them from manufacturers, healthcare facilities, and individuals. This system, however, is limited because it houses duplicate and incomplete reports. Also, the reports have not been verified, there is no causation, and national rates of incidence cannot be established (U.S. Food and Drug Administration, 2019). Currently, there is no comprehensive database to compare ADEs. I would propose that the Agency for Healthcare Research and Quality (AHRQ) incorporate ADEs as a core healthcare quality indicator and develop means of tracking data without repercussion and with anonymity. I believe that the need for more aggressive tracking is justifiable due to current evidence suggesting that most ADEs are not reported. Also, medication errors are the most common challenges within healthcare that are endangering patients worldwide (Mirzaee et al., 2015). Individuals must develop shareable and standardized tracking tools to provide transparency concerning ADEs between clinical settings and nationwide.
Causation of ADEs was discussed with errors occurring in multiple stages of administration. The stages of administration considered were prescribing, transcribing, dispensing, administration, and monitoring. The pharmacy participant reports that the most common ADEs, within the facility, occur at the dispensing and administration stages. The pharmacist did say that throughout his time as a pharmacist, he has noticed a considerable reduction in medication errors from transcribing. He attributed this reduction to the implementation of electronic medical records resulting in decreased handwritten orders. Still, however, reported medication errors cause at least 1.5 million injuries and cost 3.5 billion dollars in the U.S. annually (Shitu et al., 2020). The unfortunate part regarding ADEs in the clinical setting is that most are preventable (Bailey et al., 2016).
In my clinical setting, there have been 27 ADEs over the past three months. My facility uses the National Coordinating Council for Medication Error Reporting and Prevention (NCC-MERP) index to classify potential severity and outcome of medication errors. Twenty-three of the errors were classified as severity B. In contrast, four were classified as severity A. Both are the lowest two classifications of potential harm. Even though these severity errors posed low severity ratings, nonintervention can cause more severe errors. Knowing that most ADEs are preventable, healthcare facilities need to develop robust protocols and procedures to prevent medication errors from occurring because even one preventable ADE can be detrimental to the health of an individual.