Prostacyclin administration errors in pulmonary arterial hypertension patients admitted to hospitals in the United States: a national survey

Abstract

BACKGROUND Epoprostenol and treprostinil are intravenous prostacyclin medications used to treat pulmonary arterial hypertension (PAH). This survey explored hospital policies regarding prostacyclin infusions, and investigated the type and frequency of errors that occurred in the inpatient setting. METHODS Information on prostacyclin infusion policies and inpatient errors was obtained through detailed interviews with 18 PAH nurses, and through an electronic survey completed by 97 PAH clinicians. RESULTS The electronic survey respondents reported wide variability in prostacyclin infusion policies, including variability in the use of home vs hospital infusion pumps, and variability in the use and storage of back-up epoprostenol and treprostinil. Serious or potentially serious errors in medication administration were reported by 68% of survey respondents. The most common error types (reported by ≥25%), included: incorrect cassette placed in the pump; inaccurate pump programming; errant drug dosing; and inadvertent cessation of the pump. Nine errors, all at different centers, were believed to have contributed to patient death. In the separate interviews with the PAH nurses, 94% reported serious errors. These errors prompted many of the centers to implement policy changes in an attempt to reduce future errors, improve safety and optimize patient outcomes. CONCLUSIONS These findings suggest that prostacyclin infusion therapy is problematic and that an opportunity exists to improve safety. The development of standardized treatment guidelines should be considered.

Safety Recommendations for Administering Intravenous Prostacyclins in the Hospital

“…However, nurses' familiarity with a patient's home pump will be lower than their familiarity with a hospital pump. In the survey 16 results published in 2009, differences in error frequency between the 2 approaches were not significant. In addition, hospitals www.ccnonline.org…”

“…One article 37 outlining policies for administration of subcutaneous treprostinil has been published, but no safety guidelines for the administration of intravenous prostacyclins are available. In a previous study, 16 many errors in the administration of intravenous prostacyclin occurred. These findings suggest that prostacyclin infusion therapy is problematic and that an opportunity exists to improve safety practices for administration of this medication.…”

“…• Flushing of the dedicated prostacyclin catheter was the most commonly reported error in the survey by Kingman et al 16 The prostacyclin tubing should never be flushed, and no other medications should be coadministered.…”

“…Many pharmacists, nurses, and even physicians may have had limited experience with both the medications and the ambulatory infusion pumps. In a recent national survey, 16 68% of survey respondents reported serious or potentially serious errors in administration of intravenous prostacyclins in their hospitals. The most common errors (reported by ≥25%) included incorrect cassette placed in the pump, inaccurate pump programming, errant drug dosing, and inadvertent cessation of the pump.…”

Targeted approaches to the treatment of pulmonary hypertension

“…Although epoprostenol is the only PAH-specific therapy that has been shown to improve survival in patients with PAH [Barst et al 1996], its main drawback is its very short half life [Vane and Botting, 1995]. This becomes critical because of adverse reactions that may occur in the event of inadvertent abrupt discontinuation of the infusion [Cuiper et al 1996;Kingman et al 2010], including rebound PH, arrhythmia, and even death. Treprostinil (Remodulin, United Therapeutics Corp.) is a prostanoid with a longer half life than epoprostenol, offering less risk in the event of pump failure or inadvertent interruption of infusion.…”