Nandwana Sadhna B, Walls Deborah G, Torres William E
1 All authors: Department of Radiology, Emory University, c/o T. Easter, 1365-A Clifton Rd NE, Ste AT 627, Atlanta, GA 30322.
AJR Am J Roentgenol. 2015 Jul;205(1):90-4. doi: 10.2214/AJR.14.13884.
The purpose of this study was to identify opportunities for reducing epinephrine administration errors after a sentinel event entailing an overdose of i.v. epinephrine occurred in a radiology department.
A root cause analysis was performed that included review and analysis of current system protocols, a medication audit, and access to treatment algorithms. A proctored three-question multiple-choice test was administered to radiology attending physicians, fellows, residents, and nurses to gauge baseline knowledge of epinephrine use. Chi-square analysis was performed.
Twelve of 13 radiology department central pharmacy automation system locations lacked epinephrine ampules. As a result, personnel had to access i.v. epinephrine stocked on hospital code carts designed for use during cardiac arrest. This led to errors related to appropriate dosing. Test participants included 46 attending physicians, 23 fellows, 28 residents, and 25 nurses (n = 122). Almost all (99%) correctly identified epinephrine as the medication to administer in this situation. Approximately one half (52%) correctly identified the dose of intramuscular epinephrine, but only 29% knew the dose and rate of administration of i.v. epinephrine (p < 0.001). Attending physicians were more likely to administer i.v. epinephrine correctly than were the other groups (p < 0.0001).
Stocking and routine auditing of medication availability are essential. The use of epinephrine intended for cardiac arrest stocked on code carts should be avoided during contrast reactions. It would be optimal if first-line responders to contrast reactions included attending physicians, but this may not always be the case at academic institutions.
本研究的目的是在放射科发生静脉注射肾上腺素过量的警戒事件后，确定减少肾上腺素给药错误的机会。
进行了根本原因分析，包括审查和分析当前系统协议、药物审核以及获取治疗算法。对放射科主治医师、住院医师、实习医生和护士进行了一场有监考的三题多项选择题测试，以评估他们对肾上腺素使用的基线知识。进行了卡方分析。
13个放射科中央药房自动化系统地点中有12个没有肾上腺素安瓿。因此，工作人员不得不取用存放在医院心脏骤停急救推车上的静脉注射肾上腺素。这导致了与适当剂量相关的错误。测试参与者包括46名主治医师、23名住院医师、28名实习医生和25名护士（n = 122）。几乎所有人（99%）都正确地将肾上腺素识别为这种情况下应使用的药物。约一半（52%）的人正确识别了肌肉注射肾上腺素的剂量，但只有29%的人知道静脉注射肾上腺素的剂量和给药速率（p < 0.001）。主治医师比其他组更有可能正确静脉注射肾上腺素（p < 0.0001）。
药物库存管理和常规审核至关重要。在发生造影剂反应时，应避免使用存放在急救推车上用于心脏骤停的肾上腺素。如果造影剂反应一线急救人员包括主治医师则最为理想，但在学术机构可能并非总是如此。
