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484 Clinical Pharmacist December 2009 Vol 1
Although increasing numbers of adverse medication events are being reported to the National Patient
PRACTICE TOOLS
Safety Agency, many such occurrences still go unreported. Is there more pharmacists could be doing?
How to use “trigger drugs” to help
identify adverse medication events
By Gillian Cavell, MSc, MRPharmS
P
harmacists have the skills and remit
to identify and report adverse drug
events (ADEs), including adverse
drug reactions and medication errors. In the
UK, pharmacists working in secondary care
aim to screen all inpatient drug charts
clinically every working day. During this
process, they will encounter patients who
have been prescribed medicines to treat
ADEs or who have had medicines
discontinued because of these events.
However, on many occasions these ADEs go
unreported.
One method for promoting ADE
reporting could be to offer pharmacists
clear specifications for the types of
incidents that should be reported and
provide a tool for identifying when such
incidents occur.
Trigger drugs
Medicines prescribed and administered to
prevent harm from an ADE can be classed
as “trigger drugs”. These include antidotes
(eg, naloxone, flumazenil, vitamin K,
glucagon), medicines that treat the
symptoms of an ADE (eg, antiemetics and
antidiarrhoeals) or medicines that mitigate
the adverse event itself (eg, calcium
gluconate to treat hyperkalaemia).
The Institute for Healthcare
Improvement in the US and the Patient
Safety First campaign in the UK advocate
using a “global trigger tool” to measure
rates of patient safety events and monitor
improvements in the quality of patient care.
The tools include lists of medicines that are
indicators of possible ADEs. At King’s
College Hospital, London, we have
extended this list to include other
Gillian Cavell is consultant pharmacist
for medication safety at King’s College
Hospital NHS Foundation Trust.
E: gillian.cavell@kch.nhs.uk
Page 484
medicines that, in our experience, can also
indicate possible ADEs. A list of these
medicines, incorporating those used in the
global trigger tools and by KCH, is
provided in the Box below.
Simply monitoring the incidents where
trigger drugs are prescribed is not
sufficient. First, not all trigger drugs
indicate ADEs in every clinical setting. For
example, the need for intravenous
omeprazole on a medical ward is a good
indicator of acute gastrointestinal bleeding,
which is possibly drug-induced. However,
on a surgical ward, it might be
administered routinely following surgery.
Second, in some instances a trigger drug
might be prescribed (for use when
required) at the same time as a high-risk
medicine so that it can be administered
promptly if needed. For example, naloxone
prescribed at the same time as an opioid, or
glucagon prescribed for patients who are
receiving insulin. Here, it is important to
check whether the medicine was actually
administered.
Possible trigger drugs
DRUG
Antidiarrhoeals*
Antiemetics*
Beriplex (dried prothrombin complex)
Calcium gluconate
Chlorphenamine IV
Corticosteroids (topical)
Dextrose 20% / insulin 10 units
Diphenhydramine*
Flumazenil*†
Glucagon†
Glucose 50%†
Hydrocortisone IV
Hydroxyzine
Ion-exchange resins*
Naloxone*†
Octaplex (factor IX)
Omeprazole IV
Vitamin K (phytomenadione)*†
* Included in US trigger tool
† Included in UK trigger tool
Both UK and US trigger tools advise that abrupt cessation of any medicine might be as a result of an adverse event
IN SHORT
Pharmacists in secondary care can help
to identify adverse drug events (ADEs)
within their organisation. They can use
“trigger drugs” to help them identify
when such events take place as part of
the pharmaceutical care process.
Interventions made following
identification of an ADE can be used to
promote medication safety. This allows
pharmacists to identify recurring risks
with medicines use and contribute to
risk reduction strategies and education
within their organisations.
What can pharmacists do?
When they monitor inpatient prescriptions,
pharmacists can identify the prescribing
and administration of trigger drugs. Where
such medicines are administered,
pharmacists should be prompted to
investigate the reasons why.
Many pharmacists do not realise the
need to investigate isolated ADEs that have
POSSIBLE ADVERSE EVENT
Drug-induced diarrhoea
Nausea related to medicine use
Over-anticoagulation with warfarin
Drug-induced hyperkalaemia
Drug hypersensitivity
Drug-induced rash
Drug-induced hyperkalaemia
Drug hypersensitivity
Oversedation following benzodiazepine use
Drug-induced hypoglycaemia
Drug-induced hypoglycaemia
Anaphylaxis
Drug-induced hypersensitivity
Drug-induced hyperkalaemia
Opioid-induced respiratory distress
Over-anticoagulation with warfarin
Drug-induced gastrointestinal bleeding
Over-anticoagulation with warfarin
CP, Dec, p484-85, How to 26/11/09 10:41
been treated successfully. However, an in-
depth investigation is not needed to
determine whether an ADE has occurred; a
simple questioning approach can be
sufficient. This approach is illustrated in
the adjacent Figure — using vitamin K as
an example.
The ease with which ADEs can be
identified varies according to the specificity
of the trigger drug as an indicator of
medicines-related harm. Naloxone and
flumazenil are good indicators because they
are specific reversal agents for reactions to
opioids and benzodiazepines, respectively.
Ion-exchange resins are not so good
because hyperkalaemia, for which these
products are often prescribed, can be a
symptom of deteriorating renal function as
well as a side effect of drug therapy (eg,
with potassium supplements, potassium-
sparing diuretics or angiotensin-converting
enzyme inhibitors).
Glucagon administration can be used to
identify incidences where hypoglycaemia
has occurred. Nevertheless, the precise
cause of hypoglycaemia is often difficult to
establish.
What intervention is needed?
Pharmacists must find out why a trigger
drug has been used in each instance so that
they can identify ADEs and take steps to
prevent these recurring. It may be
necessary for them to advise medical staff
on how best to change a patient’s drug
regimen following an ADE — eg, by
reducing a dose or dosing frequency,
discontinuing a medicine or starting a
more suitable alternative.
Identifying an ADE can highlight the
need for a medicines-related discussion
with the patient, for which the pharmacist
could take the lead. For example, a patient
who is prescribed hydrocortisone and
chlorphenamine to treat a serious allergy
to a medicine will need to understand that
he or she needs to avoid that medicine in
the future. The patient should be
counselled and his or her updated allergy
status clearly documented. Also, the
patient’s GP should be informed of the
reaction upon discharge. In the case of
anaphylaxis, the patient might be advised
on where to obtain an alert bracelet.
Lack of prescriber knowledge can also
be addressed. Pharmacists who identify
patients who have become over-
anticoagulated because of a drug
interaction with warfarin should advise
medical staff on the interaction and an
alternative therapy. It is also an
opportunity to offer general information
Page 485
Vol 1 December 2009 Clinical Pharmacist 485
PRACTICE TOOLS
Figure: Example of questioning to identify an adverse drug event following vitamin K administration
Vitamin K administered to correct patient’s INR
Why did the INR need to be reversed?
Because the patient has Because the patient has Because the patient
been taking warfarin an elevated INR and is has a coagulopathy
and has become scheduled for a surgical associated with liver
over-anticoagulated procedure disease
Why was the patient NOT PREVENTABLE — no report needed
over-anticoagulated?
The correct dose The patient has The patient has An incorrect
of warfarin was been taking been prescribed a dose of warfarin
prescribed but warfarin but has medicine that has been
the wrong dose not been monitored interacts with prescribed for
was given adequately warfarin the patient
PREVENTABLE — the adverse drug event should be reported
about drug interactions with warfarin and Wider learning Incident reports should
on the occasions when patients need to be be used to identify local risks with
monitored more carefully. medicines use and prompt reviews of
ADEs resulting from medicines systems to promote safe medicines use.
administration errors can highlight issues Once incidents have been reported
with product identification (eg, because of locally, they should be passed on by the
confusing labelling or packaging, poor hospital to the National Reporting and
storage, etc) or can identify training needs Learning System (operated by the
for staff who administer medicines. Once National Patient Safety Agency). Here,
identified, these issues can be acted on and, they can be reviewed alongside those
if necessary, the lessons learnt can be fed from other organisations to identify
back to all staff using alerts, bulletins or national trends and inform learning that
teaching sessions. can be disseminated through NPSA
publications.
Learning from ADEs Where an actual or suspected adverse
Even when interventions are managed drug reaction is identified, pharmacists
within the clinical team, the opportunities should also consider reporting it to the
for wider learning must not be overlooked. Medicines and Healthcare products
Reporting ADEs, whether they result in Regulatory Agency via the yellow card
patient harm or not, is essential to enable scheme (www.yellowcard.gov.uk).
this learning. All NHS trusts have systems
in place to report ADEs. These systems
rely on staff recognising and being willing
to report such events. Although using NOTE Clinical Pharmacist PRACTICE TOOLS do not
constitute formal practice guidance. Articles in
trigger drugs is a method for prompting the
the series have been commissioned from
recognition of ADEs, staff still need to be independent authors who have summarised useful
motivated to complete the report forms. clinical skills.