NURS 1060 Exam 3 Drug Interactions, Adverse Reactions, and Errors PDF

Drug Interactions, Adverse Reactions, and Errors NURS 1060: Exam 3 Outcome  Describeprinciples of safe, patient-centered, evidence- based nursing care to adults at the basic level, guided by the Caritas philosophy.  Describequality improvement measures in healthcare micro and...

Drug Interactions, Adverse Reactions, and Errors NURS 1060: Exam 3 Outcome  Describeprinciples of safe, patient-centered, evidence- based nursing care to adults at the basic level, guided by the Caritas philosophy.  Describequality improvement measures in healthcare micro and macro systems that impact patient care. Competency  Describe factors that create a culture of safety related to medication administration.  Describequality improvement measures use to reduce medication errors. Concept  Clinical Decision Making: A process used to examine and determine the best actions to meet desired goals; requires anticipating, recognizing and organizing patient problems to respond with urgency and/or importance in a preferential order to avoid or minimize adverse changes in a patient’s condition.  Safety: Minimizing risk of human harm through both system effectiveness and individual performance.  Cultural & Diversity:  Culture – patterns of behavior and thinking that people living in social groups learn, develop, and share.  Diversity – the array of differences among individuals, groups, and communities. Unit Outcomes  Discuss concepts related to drug-drug interaction.  Identify the impact of food on drug absorption.  Define common adverse drug reactions.  Explain how to report concerns about drugs, products or equipment to the FDA  Identify the purpose of Patient Medication Guides and Boxed Warnings. Unit Outcomes  Identify types and causes of medication errors.  Identify methods to reduce medication errors.  Identifyfactors that contribute to individual variation in drug responses.  Discuss the concept of pharmacodynamic tolerance.  Define pharmacogenomics. Drug Interactions Drug-Drug Interactions  Interactionscan occur whenever a patient takes more than one drug.  Some interactions are intended and desired or unintended and undesired.  Patients frequently take more than one drug.  Multiple drugs to treat one disorder  Multiple disorders requiring different drugs  OTC meds, caffeine, nicotine, alcohol, etc. Consequences of Drug-Drug Interactions  Intensification of effects  Increased therapeutic effects  Increased adverse effects  Reduction of effects  Reduced therapeutic effects  Reduced adverse effects  Cancreate and unknown chemical when mixing two drugs that will be given parenteral  (check a drug compatibility chart)  Increased therapeutic effects Drug-Drug Sulbactam and ampicillin two separate drug combined into one antibiotic PCN Interactions + Beta Lactamase Inhibitor Sulbactam = Beta Lactamase Inhibitor Ampicillin = broad spectrum penicillin Combination prolongs and intensifies Intensificatio ampicillin effect n of Effects Increased adverse effects Examples Aspirin and Warfarin Antiplatelet + Anticoagulant = Risk for ? Drug-Drug Inhibitory – interactions that result in reduced drug effects (Reduced therapeutic effects) Interactions Propranolol and albuterol Propranolol = cardiovascular drug Albuterol = bronchodilator to treat asthma Propranolol + albuterol = propranolol reduces albuterol effects Reduction Reduced adverse effects of Effects Naloxone to treat morphine overdose Morphine reduces respirations – give naloxone to block morphine receptor binding Examples Drug-Drug  Creation of a unique or Interactions unknown response  Alcohol with Barbiturate can be lethal Examples Direct Chemical or Physical Interaction Never combine Check the drug drugs in the same compatibility container or chart or in the syringe without Electronic Clinical establishing Support system compatibility. Basic Mechanisms of Drug-Drug Interactions Pharmacokinetic Interaction Examples  Altered absorption  Drugs that depress peristalsis  Drugs that induce vomiting  Altered distribution  Competition for protein binding  Altered metabolism  Phenobarbital is an inducing agent that increases the synthesis/production of hepatic cytochrome P450 (CYP) enzymes responsible for the metabolism of many drugs  Altered renal excretion  Drugs can alter Filtration, Reabsorption, Active secretion Basic Mechanisms of Drug-Drug Interactions Pharmacokinetic Interactions  Interactions that involve P-glycoproteins (PGPs)- Transmembrane protein that transports a wide variety of drugs out of cells  Reduction or increased PGP  Intestinal epithelium: affects absorption  Placenta: affects drug export from placental cells to maternal blood  Blood-brain barrier: affects drug export from cells of brain capillaries into the blood  Liver: affects drug export from liver into bile  Kidney tubules: affects drug export from renal tubular cells into the urine   At the same receptor  Antagonist/agonist Basic  At separate receptor sites Mechanisms of  May be potentiative Drug-Drug  A potentiative effect is one in Interactions which one drug intensifies the effects of another. Pharmacodyna  Both Warfarin and aspirin suppress mic Interactions blood clotting, and the combination may increase the risk of bleeding. Minimizing Adverse Drug-Drug Interactions  Minimize number of drugs a patient receives.  Take a thorough drug history.  Adjust the dosage when metabolizing inducers are added or deleted.  Beespecially vigilant when patient is taking a drug with a low therapeutic index.  Drug-Food Interactions Drug-Food Interactions Decreased Absorption  Examples:  Calcium-containing foods  Milk and Tetracycline- calcium binds to tetracycline and is insoluble  High-fiber foods  Some drugs must be taken Drug-Food on an empty stomach. Interactions The absorption of some drugs can be significantly reduced by Timing of food; these drugs should be taken on an empty stomach, Drug which is 1 hour before a meal Administratio or 2 hours after a meal. n Other drugs should be taken with food. Drug-Food Interactions Impacting Drug Metabolism Example  The grapefruit juice effect (not occurring with other citrus fruits or juices) ONLY grapefruit juice contains 4 compounds that cause this effect  Inhibits the metabolism of certain drugs  Inhibits CYP enzyme found in the liver and also in the intestinal wall  Major effect is on oral drugs after they have been absorbed  Effect can last up to 3 days after the last glass  Raises the drugs level in blood Drug-Food Interactions Impact on Drug Action Example  Foods high in vitamin K- reduced warfarin effects Drug-Herb Interactions  Prescription and OTC drugs can interact with herbal preparations.  Interactions with herbal medicines are just as likely as with prescription medications.  Reliable information on drug-herb interactions is lacking.  Example of known interaction:  St. John’s Wort induces drug-metabolizing enzymes and reduces blood levels of many drugs. Adverse Drug Reactions  Adverse drug reactions (ADRs) Two Related Also known as adverse Issues of drug events (ADEs) Drug Safety Medication errors Adverse Drug Reactions = any unintended or undesired effect that occurs at doses normally used for treatment  Excludes excessive dosages  Can range from annoying to life-threatening  Defined by the World Heath Organization Adverse Drug Reactions Scope of the Problem  Mild reactions  Drowsiness, nausea, itching, and rash  Severe reactions (potentially fatal)  Respiratory depression, neutropenia, hepatic injury, anaphylaxis, hemorrhage  Most common in the elderly and very young Terms Related to Adverse Drug Reactions Side effect = A nearly unavoidable secondary drug effect produced at therapeutic doses May develop soon after drug is initiated or not until drug has been taken for weeks or months Toxicity = the degree of detrimental physiologic effects caused by excessive dosing (or decreased metabolism or excretion, decreased hepatic or renal function) Terms Related to Adverse Drug Reactions Allergic reaction = Immune response: Occurs with the second dose or later doses Requires sensitization of the immune system Patient’s sensitivity to a drug can change over time. Very few drugs cause severe allergic reaction. Most common examples: Penicillins, Sulfonamides Idiosyncratic effect =An uncommon drug response resulting from a genetic predisposition Example: Succinylcholine-induced paralysis Usually brief paralysis like during surgery Idiosyncratic effect- May last for hours in genetically predisposed patient Terms Related to Adverse Drug Reactions Iatrogenic disease Iatrogenic = disease produced by drugs Example: drugs for antipsychotic disorders can cause Parkinson’s-like symptoms) Teratogenic effect Drug-induced birth defect Hepatotoxic Drugs  Can cause of liver failure  As some drugs undergo metabolism, they are converted to toxic products that can injure liver cells.  Combining hepatotoxic drugs may increase the risk for liver damage—for example, acetaminophen and alcohol.  Monitor labs: aspartate aminotransferase (AST) and alanine aminotransferase (ALT) for liver injury. Nephrotoxic Drugs  Cancause acute or chronic damage to the kidneys  Sometimes caused by IV contrast given for CT scans or other radiology tests  Monitor urine output, labs- BUN and Cr Drugs and Life-Threatening Dysrhythmias  Some drugs increase risk to develop life-threatening dysrhythmias  Dysrhythmia Examples:  Torsades - a form of ventricular tachycardia  V-fibrillation - if Torsade recurs and may degenerate into ventricular fibrillation.  Minimizing the risk  Monitor heart rhythm- EKG, telemetry  Monitor electrolytes- (low potassium and low magnesium- risk for dysrhythmias) Identifying Adverse Drug Reactions  Did symptoms appear shortly after the drug was first used?  Did symptoms stop/decrease when the drug was discontinued?  Did symptoms reappear when the drug was reinstituted?  Is the illness itself sufficient to explain the event?  Are other drugs in the regimen sufficient to explain the event? Black Boxed Warnings Strongest safety warning a drug can carry and still remain on the market Used to alert providers to potential side effects and to ways to prevent or reduce harm from these side effects. Placed on any drug that, although useful, has serious side effects; this is a way to keep drugs on the market while protecting patients. Black Box Warning Example  Fluoroquinolone Antibiotics According to the FDA, people taking a fluoroquinolone antibiotic have an increased risk of tendinitis and tendon rupture, a serious injury that could cause permanent disability. The FDA warning includes Cipro (ciprofloxacin), Levaquin (levofloxacin), Avelox (moxifloxacin) and other medications containing fluoroquinolone. (Warning issued July 2008.) Medication Errors Medication Errors  Risk for error in hospitals is high because each medication order is processed by several people.  Thenurse is the last person in this sequence.  Thus, the nurse is the last line of defense against mistakes.  This places a heavy responsibility on the nurse for ensuring patient safety. Categories of Serious Med Errors 90% percent of fatal or serious medication errors fall into three categories:  Human factors;  Giving a drug IV (intravenously) instead of IM (intramuscularly)  Communication mistakes;  Writing a prescription so that it is illegible  A complete order; contains the medication, dose, route, and time.  Unacceptable abbreviations; QD; it should be written out as “daily”; U should be units  Name confusion;  Giving a drug with a name that sounds like the name of another drug  Electronic order entry Encourage patients be active, Methods to informed members of the healthcare team Reduce Cultivate a just/fair environment Medication Address system problems instead of individual Errors shaming Institutional culture dedicated to safety Tools/information needed to prescribe, dispense, and administer drugs safely  Case Study  A patient was admitted to the hospital to receive a regimen of furosemide.  A correct order was written by the physician and appropriately sent to the pharmacy. Case Study Continued A pharmacist erroneously entered twice the written dose of furosemide into the computerized medication administration record (MAR). A second pharmacist, who was expected to independently compare the MAR, to the physician’s order, initialed the prepared medication as correct. Case Study Continued  The incorrect dose was sent to the floor. The administering nurse appropriately checked for the two pharmacists' signatures, but was also expected to, along with a second nurse, to independently compare the dose on the medication to the written physician order. Both nurses initialed the medication as correct, and the drug administration was initiated. Case Study Continued  Before all of the medication had infused, there was a change in nursing shift. The next nurse, compared the dose on the medication bag to the written order, discovered the error, immediately stopped the furosemide, assessed the patient, called the attending physician and averted an adverse drug event (ADE) for the patient.   Who made an error?  How did they make and error? Case Study  What can be done to prevent Reflection this error from occurring in the future to another patient? Clinical Decision-Making Question  Situation:Patient was given a medication that was not ordered for them?  What is the FIRST action of the nurse after identifying a medication error has occurred?  50% of all new drugs have serious ADRs that are not revealed during Phase II and Phase III trials. Adverse Reactions Be alert for unusual responses when giving new drugs. to New Drugs Drugs that you suspect of causing a previously MedWatch: the FDA Medical unknown adverse Products effect should be Reporting Program reported MedWatch FDA Medical Products Report online Voluntary reporting by healthcare professionals of Reporting Program www.fda.gov/medwat serious harm to a patient ch Anycaused drug: newby; and old Products : example Baby formula Medical equipment: example IV pump Individual Variation in Drug Response Individual = Factors that cause Variation in one patient to respond Drug to drugs differently than another patient Responses Individual Variation in Drug Responses Pathophysiology Liver disease Kidney disease Reduced metabolism and increased Reduced excretion and increased toxicity toxicity Age and Variation in Drug Responses  Older adults and infants are the two groups most sensitive to drugs because of differences in organs that absorb, metabolize, and excrete drugs.  In the older adult, organ degeneration accounts for these differences, whereas in infants the differences are related to organ immaturity. Biological Sex and Variation in Drug Responses  Until 1997, almost all clinical drug trials were performed on males.  Females may have more toxic effects with some drugs and fewer toxic effects with others. Not all drugs are influenced by hormonal changes. Females metabolize some drugs more slowly and other drugs more quickly.  Unless drug trials are performed in both females and males, the effects of drugs in women will not be clear. Individual Variation in Drug Responses Tolerance  Toleranceis a decreased responsiveness to a drug as a result of repeated drug administration  Higher doses required to get the desired affect  Common categories of drug tolerance  Pharmacodynamic tolerance  Metabolic tolerance   Results when a patient takes a drug over a period of time.  Adaptive processes occur in response to chronic receptor occupation. The Pharmacodynami result is that the body c Drug Tolerance requires increased drug, or an increased MEC, to achieve the same effect.  Often occurs with opioid narcotic analgesics for chronic pain   Resultingfrom accelerated drug Metabolic metabolism Drug  Example: Tolerance Phenobarbital increases enzyme production Pharmacogenomic s = study of how genes affect individual drug responses Pharmacogenomics Genetics can impact:  Drug metabolism  May accelerate or reduce the rate of metabolism  Drug receptors  Geneticvariations alter the structure of drug receptors.  Individual may not have the receptor required for “Lock and Key” fit Pharmacogenomics  Individual Pharmacogenomics is the study of the ways genetic variations cause individual responses to drugs through a person’s unique genes that provide their code for drug- metabolizing enzymes and drug receptors.  Future Possibilities:  Pharmacogenomic may be used to determine if a drug will or will not help an individual  In theory, stop “trial-and-error” approach of prescribing