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 backup 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.

Intra-abdominal bleeding during treprostinil infusion in a patient with pulmonary arterial hypertension

“…A recent survey reported that technical errors in the administration of treprostinil are very common, and can contribute to a fatal outcome10; however, a thorough review of our files did exclude any mistakes in the administration procedures.…”

Management of the Patient With Pulmonary Arterial Hypertension Receiving Intravenous Prostacyclin

“…6,7,20,36,37 Dosage escalation needs to be made in minute increments as sudden increases or decreases in the dose can be life threatening. When patients are admitted to the hospital, the hospital pharmacist should contact the patient's specialty pharmacy to verify current dose, dosing weight, concentration, and pump rate.…”

Current and Emerging Therapies for Pulmonary Arterial Hypertension

“…General supportive measures are listed in Table 3. 16 The decision regarding initial therapy must be individualized and incorporates many factors and determinants of risk, including WHO functional class, progression of symptoms, hemodynamic assessment, 6-minute walk test, biomarkers of severity, comorbidities, access to emergent care, and psychosocial support.…”

“…13,14 There are also numerous potential infusion-related complications, such as sepsis, thrombus, infection, subcutaneous site pain, and rebound pulmonary hypertension resulting from administration interruptions; therefore, treatment should only be initiated by experienced providers and ideally only by a pulmonary hypertension specialist. [8][9][10][11]15,16 Treatment with a PGI 2 may not be appropriate for all PAH patients. Patients with reduced visual acuity or manual dexterity issues may find it challenging to operate the drug delivery device, regardless of the route of administration ( Table 2).…”

“…General supportive measures for patients with pulmonary arterial hypertension16 Symptom-limited exercise Avoid hypobaric environments, including high-altitude travel, if possible Avoid medications with vasoconstrictive properties (eg, pseudoephedrine) Discourage pregnancy due to high maternal mortality; avoid oral contraceptives with prothrombotic propertiesMedical therapyAnticoagulation to a target INR of 1.5 to 2.5; recommended for most patients Oxygen supplementation for hypoxemia Diuretics for management of edema or fluid retention, especially in the setting of right ventricular failure Consider digoxin, particularly for patients with a high sympathetic activation or with concomitant atrial fibrillaton or biventricular failure Long-term calcium channel blockers for patients who have a positive acute vasoreactivity test and calcium channel blocker challenge without significant side effects; less than 7% of patients are in this subgroup Note: INR 5 international normalized ratio.…”