Supratherapeutic Dosing of Acetaminophen Among Hospitalized Patients

Zhou, Li; Maviglia, Saverio M.; Mahoney, Lisa M.; Chang, Frank Y.; Orav, E. John; Plasek, Joseph M.; Boulware, Laura J.; Lou, Hong; Bates, David W.; Rocha, Roberto A.

doi:10.1001/2013.jamainternmed.438

Cited by 20 publications

(30 citation statements)

References 19 publications

(22 reference statements)

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“…In fact the proportion of patients that were exposed to more than 4 g paracetamol during their hospitalization was 6Á0% in our setting and therefore almost identical to the number reported by Zhou et al in a similar setting in the United States. 5 However, a single day with administration of only little more than 4 g paracetamol, although a formal medication error, is usually clinically irrelevant. In order to avoid alert fatigue, proactive safety systems therefore have to find a rational alerting threshold for medication errors that are relevant and require prescription changes.…”

Section: Resultsmentioning

confidence: 99%

“…1,4 Zhou and colleagues recently investigated the frequency of unintentional paracetamol overdosing in a tertiary care hospital and reported that 6Á6% of paracetamol users exceeded the recommended maximum dose of 4 g/day. 5 Civan et al performed a similar analysis and reported overdosing in 2Á6%. 6 In hospitals that use clinical information systems (CIS) with computerized physician order entry (CPOE), all prescriptions are electronically documented, and integrated clinical decision support systems (CDSS) may in theory detect and prevent many medication errors including paracetamol overdosing.…”

Section: What Is Known and Objectivementioning

confidence: 86%

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Paracetamol overdosing in a tertiary care hospital: implementation and outcome analysis of a preventive alert programme

et al. 2016

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WHAT IS KNOWN AND OBJECTIVES Paracetamol is a frequently used antipyretic and analgesic drug, but also a dose-dependent hepatotoxin. Unintentional paracetamol overdosing is a common medication error in hospitals. The present study aimed at (i) analysis of unintentional paracetamol overdosing in hospitalized patients; (ii) development, implementation and outcome analysis of an alert algorithm for the prevention of relevant paracetamol overdosing. METHODS All patients who received paracetamol in a Swiss tertiary care hospital during 2011 to 2014 were analysed to detect cases of paracetamol overdosing in a local pharmacoepidemiological database. In 2014, an automated algorithm screened the hospital's electronic prescribing system for patients at risk of overdosing, followed by expert validation. When imminent relevant overdosing was confirmed, alerts were issued to prescribers. Relevance was defined as prescriptions that permitted repeated daily paracetamol exposure of 5 g. RESULTS AND DISCUSSION From 2011 to 2013, relevant overdosing occurred in 11 patients (5-8 g/day for 3 to 5 days), which corresponds to 0·4 % of all patients exposed to any paracetamol overdosing (mean n = 988 per year). In 2014, alerts were issued by experts in 23 cases with subsequent changes to prescriptions in 21 (91·3 %) thereof. Although the occurrence of any paracetamol overdosing declined only marginally in 2014 (n = 914), no relevant overdosing occurred anymore. WHAT IS NEW AND CONCLUSION Unintentional paracetamol overdosing was frequent but only a small fraction thereof was deemed relevant. This proof of concept study analysed local hospital data and developed a preventive system combining sensitive automated detection with subsequent specific expert validation. The resulting alerts achieved high compliance and prevented relevant paracetamol overdosing. SUMMARYWhat is known and objectives: Paracetamol is a frequently used antipyretic and analgesic drug, but also a dose-dependent hepatotoxin. Unintentional paracetamol overdosing is a common medication error in hospitals. The present study aimed at 1)Analysis of unintentional paracetamol overdosing in hospitalized patients; 2)Development, implementation and outcome of an alert algorithm for the prevention of considerable paracetamol overdosing. Methods:All patients who received paracetamol in a Swiss tertiary care hospital during 2011 to 2014 were analysed to detect cases of paracetamol overdosing in a local pharmacoepidemiological database. In 2014 an algorithm screened the hospital's electronic prescribing system for patients at risk of considerable overdosing, followed by expert validation. When such overdosing was confirmed as imminent, alerts were issued to prescribers. Considerable overdosing was defined as prescriptions that permitted repeated daily paracetamol exposure of ≥ 5 g. Results and What is new and Conclusion:This proof of concept demonstrates that analyzing local hospital data allows the development of alert algorithms that successfully prevent relevant medi...

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Section: Resultsmentioning

confidence: 99%

Section: What Is Known and Objectivementioning

confidence: 86%

Paracetamol overdosing in a tertiary care hospital: implementation and outcome analysis of a preventive alert programme

et al. 2016

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“…In our seven-day study focusing on acetaminophen prescriptions in Rennes University Hospital, around three quarters of prescriptions were full-dose (4 g/day); in this group, 47 % of prescriptions were for patients with at least one HRF: these can be considered as non-compliant prescriptions, and the proportion is greater than in previous studies showing up to 21 % of non-compliant acetaminophen prescriptions in hospital [27][28][29][30][31]. The lower non-compliant prescriptions could be related to the fact that age > 75 years is not considered as a HRF in SmPC and no dose adjustment is recommended.…”

Section: Discussionmentioning

confidence: 87%

“…Few studies have described acetaminophen prescription patterns in hospitals or assessed compliance with recommendations relating to HRFs: in French and American cohorts, failure to adjust doses in view of the presence of HRFs was observed in 1 % to 21 % of prescriptions [27][28][29][30][31]. It can be noted that neither the type of hospital units (surgery, geriatrics...) nor pharmaceutical validation studies have an influence on dose adjustment [27,30].…”

mentioning

confidence: 99%

Hepatotoxicity risk factors and acetaminophen dose adjustment, do prescribers give this issue adequate consideration? A French university hospital study

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Gilardi

et al. 2019

Eur J Clin Pharmacol

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“…Adverse events from premedications were not obtained in our population due to the non‐specific side effect profiles of acetaminophen and diphenhydramine and the lack of associated ICD codes. It is notable, however, that both medications have been associated with significant adverse events in hospitalized patients . Diphenhydramine, in particular, has been associated with a 22% increase in hospital‐acquired delirium and is included in the Beers List for Potentially Inappropriate Medication Use in Older Adults due to its strong anticholinergic properties.…”

Section: Discussionmentioning

confidence: 99%

A retrospective cost analysis of the frequency and cost of transfusion premedications

et al. 2019

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BACKGROUND: Acetaminophen and diphenhydramine are routinely administered to prevent febrile nonhemolytic and allergic blood transfusion reactions despite multiple randomized controlled trials demonstrating that this practice lacks efficacy. As a result, patients are exposed to the adverse effects of these medications and their financial burdens with no expected benefit. The aim of this study was to quantify the frequency and cost of transfusion premedications in patients with acute myeloid leukemia (AML). STUDY DESIGN AND METHODS:This was a retrospective study of patients with AML admitted to Vanderbilt University Medical Center (VUMC) for induction chemotherapy between January 2008 and December 2016. Data were collected on the number of platelet and packed red blood cell (PRBC) transfusions each patient received during the initial inpatient encounter for AML, as well as on the administration of premedications prior to each transfusion. RESULTS:During the 9-year study period, 948 AML patients received a total of 19,820 transfusions. Of these, 30% were preceded by oral diphenhydramine, 8% by intravenous diphenhydramine, and 39% by oral acetaminophen. The percentage of patients that received a transfusion preceded by a premedication increased over the study period (p = 0.03), as did the percentage of transfusions preceded by a premedication (p = 0.02). The total unadjusted cost of pre-transfusion medications to the institution during the study period was $50,309.77, or $52.67 per patient with AML. The cost of premedications per patient did not increase over the study period (p = .45).

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Supratherapeutic Dosing of Acetaminophen Among Hospitalized Patients

Cited by 20 publications

References 19 publications

Paracetamol overdosing in a tertiary care hospital: implementation and outcome analysis of a preventive alert programme

Paracetamol overdosing in a tertiary care hospital: implementation and outcome analysis of a preventive alert programme

Hepatotoxicity risk factors and acetaminophen dose adjustment, do prescribers give this issue adequate consideration? A French university hospital study

A retrospective cost analysis of the frequency and cost of transfusion premedications

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