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To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.annemergmed.2009.12.017 Byline: Asad E. Patanwala (a), Terri L. Warholak (a), Arthur B. Sanders (b), Brian L. Erstad (a) Abstract: We determine the rate and severity of medication errors, as well as factors associated with error occurrence in the emergency department (ED). Author Affiliation: (a) Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Tucson, AZ (b) Department of Emergency Medicine, University of Arizona, Tucson, AZ Article History: Received 23 October 2009; Revised 18 November 2009; Accepted 11 December 2009 Article Note: (footnote) Please see page 523 for the Editor's Capsule Summary of this article., Supervising editor: Robert L. Wears, MD, MS, Author contributions: AEP, TLW, ABS, and BLE conceived and designed the study. AEP performed all data collection. AEP and BLE conducted data analysis and drafted the article. TLW and ABS contributed substantially to its revision. AEP takes responsibility for the paper as a whole., Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. This research was supported by a junior investigator grant from the American Society of Health-System Pharmacists Foundation., Reprints not available from the authors., Publication date: Available online January 15, 2010.

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.annemergmed.2009.12.017 Byline: Asad E. Patanwala (a), Terri L. Warholak (a), Arthur B. Sanders (b), Brian L. Erstad (a) Abstract: We determine the rate and severity of medication errors, as well as factors associated with error occurrence in the emergency department (ED). Author Affiliation: (a) Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Tucson, AZ (b) Department of Emergency Medicine, University of Arizona, Tucson, AZ Article History: Received 23 October 2009; Revised 18 November 2009; Accepted 11 December 2009 Article Note: (footnote) Please see page 523 for the Editor's Capsule Summary of this article., Supervising editor: Robert L. Wears, MD, MS, Author contributions: AEP, TLW, ABS, and BLE conceived and designed the study. AEP performed all data collection. AEP and BLE conducted data analysis and drafted the article. TLW and ABS contributed substantially to its revision. AEP takes responsibility for the paper as a whole., Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. This research was supported by a junior investigator grant from the American Society of Health-System Pharmacists Foundation., Reprints not available from the authors., Publication date: Available online January 15, 2010.

Background: Crystalloids, nonprotein colloids (NPCs), and albumin are used for many indications. The use of the least costly agent in situations where these products are clinically interchangeable can reduce health care costs. Objectives: To characterize the prescribing of albumin and NPC. To evaluate the appropriateness and cost implications of their use. Methods: An observational study conducted in 15 academic health centers from April 11 through May 6, 1994, to assess the appropriateness of albumin and NPC use, based on 'model' consensus-derived indication guidelines. Results: A total of 969 case report forms were evaluated. Albumin and NPCs were administered in 83% and 17% of the cases, respectively. Albumin and NPCs were administered mostly in the intensive care (50%) or operating room (31%) settings. The most common prescribers of these products were surgeons (45%) and anesthesiologists (20%). In 87% of cases, albumin or NPC was administered to reach a defined end point (eg, to achieve a target physiological state or to resolve a pathophysiological condition). Only one albumin recipient experienced an adverse event; no adverse events were noted with NPC administration. Approximately $203 000 was spent on albumin and NPC therapy for the 969 cases; $49 702 (24%) was spent on appropriate administrations, $124939 (62%) on inappropriate administrations, and $28014 (14%) on unevaluated indications. Conclusions: Evaluated against model guidelines, most of the albumin and NPC use in the study was found to be inappropriate. The need for institutions to define and implement guidelines that focus on the cost-efficient use of these agents is recommended in an increasingly cost-conscious health care environment. (Arch Intern Med. 1995;155:2450-2455)

Objective: To develop contemporary, comprehensive guidelines for the appropriate and efficient use of albumin, nonprotein colloid, and crystalloid solutions. Design: A systematic, literature-based, consensus exercise employing a modified Delphi method. Participants: Thirty-one medical and allied health professionals from 26 University Hospital Consortium (Oak Brook, Ill) member institutions were initially chosen to participate. Participants were selected on the basis of their recognized research in the use of albumin, nonprotein colloid, and crystalloid solutions, and/or experience in the review of appropriateness of such use. A total of 24 participants completed the exercise. Main Outcome Measures: Group responses were statistically analyzed in an iterative consensus development process. Five separate questionnaire rounds were designed to establish criteria for the appropriate use of albumin, nonprotein colloid, and crystalloid solutions. Results: Consensus guidelines were developed outlining the appropriate use of these products for 12 clinical indications, including hemorrhagic shock, nonhemorrhagic (maldistributive) shock, hepatic resection, thermal injury, cerebral ischemia, nutritional intervention, cardiac surgery, hyperbilirubinemia of the newborn, cirrhosis and paracentesis, nephrotic syndrome, organ transplantation, and plasmapheresis. Conclusion: The Delphi method, a systematic, literature-based consensus process, was shown to be useful in the development of complex clinical practice guidelines for the use of albumin, nonprotein colloid, and crystalloid solutions. It is anticipated that the guidelines will assist health care providers to develop local institutional policies and procedures for the appropriate and efficient use of albumin and albumin alternatives. Institutions reviewing and updating existing local guidelines may use the University Hospital Consortium guidelines as a model for comparison.

A review is presented of the medical literature concerning the clinical uses of albumin, a protein normally found in the blood. These include giving albumin as a supplement in transfusions for people with serious injuries or who are undergoing surgery. It may be administered until an optimal level in the blood is reached, or according to empirical formulas, to normalize hemodynamic variables such as arterial blood pressure. Albumin has also been used to treat patients with pulmonary insufficiency (a condition in which the lungs do not oxygenate the blood sufficiently); during open-heart surgery; for treating burn patients; and for treating patients with cirrhosis (a chronic liver disease) or nephrosis (a degenerative kidney disorder). Albumin has been administered as a nutritive supplement to patients undergoing enteral feeding (by means of a tube) or total parenteral nutrition (intravenous feeding). Other uses are also discussed. In summary, the clinical use of albumin is controversial; it is expensive but offers the advantage over blood products of not carrying viral contaminants. Albumin does not appear to be more effective than crystalloid solutions (which diffuse across membranes) as a transfusion agent in many circumstances, but it may be beneficial for the elderly who cannot be given the larger fluid volumes used for crystalloid solutions. More research is needed to compare the effectiveness of albumin with that of crystalloid solutions; the latter are relatively inexpensive. (Consumer Summary produced by Reliance Medical Information, Inc.)

Amiodarone is a drug used to manage life-threatening ventricular tachyarrhythmias, where the heart beats wildly and irregularly. Phenytoin is normally used for the treatment of seizures, yet it seems to have some effectiveness in treating some ventricular arrhythmias as well. There is evidence that the levels of phenytoin are greater in patients also taking amiodarone; this has been confirmed in healthy volunteers. Furthermore, research has shown that this is because the amiodarone inhibits the metabolism of phenytoin, so that it is broken down more slowly. In order to determine the effect this would have on patients taking phenytoin on a daily basis, the steady-state blood levels of phenytoin were measured in healthy volunteers over a period of two weeks. The subjects received two to four milligrams of phenytoin per kilogram of body weight each day; the calculated dose was rounded off to the nearest 100 milligram capsule. After six days, 200 milligrams of amiodarone were added to the drug regimen. The serum concentration of phenytoin increased, and a concomitant decrease was seen in the urinary excretion of phenytoin metabolites. The increase in phenytoin was sufficiently large to recommend that for patients on phenytoin, the dose be reduced between 25 and 30 percent if amiodarone is to be added to the therapeutic regimen. (Consumer Summary produced by Reliance Medical Information, Inc.)