Guest blog by Andrew Combs, M.D., Ph.D. Learn more about Dr. Combs’ role within Pediatrix below.
World Patient Safety Day is September 17, 2022. The World Health Organization has designated Medication Safety as the theme this year, with the slogan “Medication Without Harm.”
Medication errors are a leading cause of patient harm. The Institute of Medicine estimated that medication errors occur at a rate of one error per day per hospitalized patient. Errors also occur in outpatient and community settings.
Most of us are familiar with efforts to reduce the chance of medication errors. These include:
- Computerized physician order-entry systems in hospitals
- Electronic prescribing for outpatient pharmacies
- Bar-codes on medications and patient wrist bands to minimize wrong-patient and wrong-drug errors
- Two-nurse cross-checks for high-risk medications
- Changes to the labeling of medication vials to avoid confusion between low-dose versus high-dose formulations
Yet despite these innovations, errors still occur with a surprising frequency. In this article, we will discuss some medication safety issues that are especially relevant to obstetrical care and some that are relevant to all health care providers.
Overuse of antibiotics results in selection for resistant bacteria. In the long run, this renders our antibiotic armamentarium ineffective. The Centers for Disease Control and Prevention (CDC) lists 21 organisms as antibiotic resistance threats, including five classified as urgent threats (C. difficile, drug-resistant gonorrhea and others), 11 as serious threats (MRSA, resistant tuberculosis and others) and five as concerning or “watchlist” threats. The CDC is concerned that not enough new antibiotics are in development to fill the void as existing antibiotics become ineffective due to resistance.
The CDC outlines several Core Elements of Antibiotic Stewardship for both hospital and outpatient settings. Elements that are especially relevant for obstetrics include:
- Do not use antibiotics for suspected viral infection (for example, typical cold or flu-like syndromes).
- Select an antibiotic with the narrowest spectrum to cover the suspected organism(s). For example, for pre-op prophylaxis before cesarean, a first-generation cephalosporin like cefazolin is preferred over second-generation cephalosporins because it has comparable effectiveness and will cause less resistance.
- After starting empiric therapy for suspected infections (examples include cystitis or postpartum endomyometritis), follow-up culture results and modify the antibiotic regimen to match the organism(s) identified.
- Do not use empiric antibiotic treatment for patients with preterm labor (PTL) and intact membranes with an aim to increase latency to delivery. Such empiric treatment may paradoxically shorten the time to delivery in most cases in which there is no microbial invasion of the amniotic fluid. On the other hand, antibiotic prophylaxis is recommended for PTL patients with unknown group-B strep status if delivery is imminent; penicillin or ampicillin is preferred (narrow spectrum). Antibiotic prophylaxis is also recommended for preterm prelabor rupture of membranes; a combination of ampicillin plus a macrolide (erythromycin or azithromycin) is preferred.
No more “baby aspirin”
Low-dose aspirin is used during pregnancy to reduce the risk of preeclampsia in patients with risk factors. It is potentially dangerous to use the phrase “baby aspirin” to describe low-dose aspirin.
Aspirin given to infants and children can trigger Reye Syndrome, a severe and sometimes lethal encephalopathy (brain damage). Public health efforts in the 1980s educated patients and providers about the potential dangers of aspirin use in infants and children, but these educational programs happened before current pregnant patients and many current providers were born.
It makes no sense to use the word “baby” to describe a medicine that we are recommending to a patient who will soon have a baby in the house. If we call it “baby aspirin,” many patients mistakenly believe that low-dose aspirin is intended for babies, which it is not. Use of this phrase increases the chance that some well-meaning parent, grandparent or other caregiver will unwittingly give aspirin to an infant and cause Reye Syndrome.
Moreover, there has been no product labeled “baby aspirin” in the US since 2012, so patients will be unable to find “baby aspirin” in their pharmacy or store. Rather than ask the pharmacist for help, some patients may simply not take any aspirin because they cannot find “baby aspirin.” Some patients may substitute full-dose aspirin and others may substitute “children’s acetaminophen.” These alternatives fail to achieve the desired benefit.
We should continue recommending low-dose aspirin for patients at risk, but we must stop calling it “baby aspirin.”
Judicious use of antenatal corticosteroids (ACS)
ACS have tremendous benefits for preterm newborns if given to pregnant patients within one week before preterm birth. Proven benefits include reductions in respiratory distress syndrome, intraventricular hemorrhage, necrotizing enterocolitis and death. The American College of Obstetricians and Gynecologists recommends ACS for all patients at risk of preterm birth within one week up to 34 weeks of gestation, and The Society for Maternal-Fetal Medicine (SMFM) further recommends ACS for selected patients up to 36 weeks, 5 days.
Although ACS are beneficial if given within one week of preterm birth, they are of no benefit if given more than one week before birth and may have long-term adverse effects if given in the preterm period but the birth occurs at term.
For most medications, the indication for use is that a patient has a given condition. But for ACS, the indication is that a patient is “at risk” for a condition: preterm birth within seven days. Thus, to time ACS optimally, we must be able to predict the future: will this patient deliver within seven days or not? We are limited in our ability to predict this accurately. Several studies have found that less than half of births before 34 weeks in the US and Canada received ACS within seven days. Although up to 80% received ACS at some point before birth, in most cases ACS were given more than seven days prior and thus had no benefit.
Until 2020, The Joint Commission (TJC) required its accredited hospitals to report on a metric that assessed whether ACS were given before early preterm births. The metric encouraged aggressive use of ACS and the rate improved in TJC hospitals from 80% in 2012 to 98% in 2017. However, this metric did not assess whether ACS were given within the optimal seven-day window. Most of these patients likely received ACS too early to be of benefit.
SMFM has developed new quality metrics that assess whether ACS are given within seven days (optimally timed) or given too early. It will be impossible for facilities to reach 100% on the optimal timing metric, but a shift from aggressive use to more judicious use of ACS should result in improvement from the current rate of less than 50%.
Read-back of verbal orders
If you order a pizza on the phone or give someone your phone number or credit card number, it is common for the recipient to repeat the information back to you. It is understood that even straightforward information can be misheard over the telephone, especially in high-stress or noisy environments. It is no different with verbal orders given by physicians or nurses, yet these highly trained professionals often do not fully appreciate the likelihood that a medication name may be misinterpreted or a dosage confused. The result can be disastrous.
TJC standards require the receiver of a verbal order to record it and read it back to the prescriber. At some hospitals, nurses are required to document that they have performed read-back of a verbal order by recording “RBVO” or something similar in the chart; audits show a very high rate of writing this. However, this only assures us that nurses are writing that they have done a read-back, not that they are actually doing it. Actual performance of the readback is much lower. A recent survey of nurses and pharmacists reported that almost half admitted that they performed a read-back less than half the time.
The responsibility of assuring that a read-back happens belongs to both the giver and the recipient of a verbal order. If the nurse receiving a verbal order does not spontaneously read back the order, the physician giving the order should politely ask, “read-back, please.” Patient safety demands that we develop the habit of doing this.
Abbreviations to avoid
Since 2001, TJC has had a Do Not Use list enumerating abbreviations that have repeatedly been confused or misinterpreted, leading to medication error.
Many hospital pharmacies reject orders written with these abbreviations, so providers generally learn not to use them in their medication orders. However, providers may persist in using these abbreviations in their chart progress notes and their hand-off summaries, where their use is not penalized. Such usage is an example of “normalization of deviance” – if we remain in the habit of using these abbreviations in some contexts, we risk inadvertently using them for medication orders, where they can be dangerous. It is far better for us to discipline ourselves not to use them anywhere, ever, and to correct each other if we slip.
About Andrew Combs, M.D., Ph.D.:
Andrew Combs, M.D., Ph.D., has practiced as a board-certified maternal-fetal medicine (MFM) specialist at Obstetrix of San Jose, part of Pediatrix® Medical Group, in California since 1993. Dr. Combs also serves as senior advisor for MFM quality for the Pediatrix Center for Research, Education, Quality and Safety.
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