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Although snake bites are rare in Europe, there are a constant number of snake bites in Switzerland. There are two domestic venomous snakes in Switzerland: the aspic viper (Vipera aspis) and the common European adder (Vipera berus). Bites from venomous snakes are caused either by one of the two domestic venomous snakes or by an exotic venomous snake kept in a terrarium. Snake- bites can cause both a local and/or a systemic envenoming. Potentially fatal systemic complications are related to disturbances of the hemostatic- and cardiovascular system as well as the central or peripheral nervous system. Beside a symptomatic therapy the administration of antivenom is the only causal therapy to neutralize the venomous toxins.

Introduction: Methotrexate is used to treat many medical conditions with medication schedules that differ widely in dosage and frequency. The high potential of erroneous too frequent low-dose methotrexate prescriptions leading to severe adverse reactions is well known; however, documentation is mainly limited to case reports. We reviewed all methotrexate prescriptions in a secondary and a tertiary care hospital to analyse the incidence of too frequent low-dose methotrexate prescriptions, and assessed the quality assurance concepts implemented., Methods: All nononcological low-dose methotrexate prescriptions issued for inpatients within 55 months were analysed to identify too frequent prescriptions potentially leading to harmful overdosing. Subsequently, clinical pharmacologists reviewed all new methotrexate prescriptions with resulting interventions at the physician level in the tertiary care hospital. The impact of an interruptive alert displayed at methotrexate order entry was assessed in the secondary care hospital., Results: The incidence of too frequent prescriptions at the tertiary hospital was 1.6% (five medication errors and nine near misses in 888 inpatients). After introducing checks by pharmacologists, two prescription errors were intercepted during the 8 month quality assurance period. At the secondary care hospital the incidence dropped from 2.5% (2/79, 20 months) to 0.8% (1/123, 35 months) after the alert was implemented., Conclusions: The incidences of erroneous too frequent low-dose methotrexate prescriptions observed at both hospitals were considered too high due to the high potential for increased morbidity, mortality and costs. Therefore, quality assurance measures were implemented and the preliminary data show a positive impact on patient safety for both approaches.

Computer-triggered reminders alerting physicians on every potentially harmful drug-drug-interaction (DDI) induce alert fatigue due to frequent messages of limited clinical relevance. On demand DDI-checks, however, are not commonly used by physicians. Optimal strategies for sustained quality assurance have to consider patients' risk factors and focus on the most significant DDIs only. An approach is proposed based on the analysis of concurrent prescription of potassium-sparing diuretics and potassium supplements (CPPP), which are the most frequent DDIs classified as contraindicated. Although the frequency of monitoring potassium serum levels declined during prolonged periods of CPPP, the likelihood of observing a hyperkalaemia increased. The median treatment period of CPPP was 3.3 days, whereas hyperkalaemia occurred after a median observation time of 4.5 days of CPPP. Thus, computer-triggered reminders for ordering potassium serum levels may be indicated if monitoring has been discontinued after 48h of CPPP.