Search

Background: Since most patients with moderate, major or fatal outcomes are hospitalized, PC hospital consultation rates (HCR) indicate the degree of a PC's utilization in serious poisonings (PO). The purpose of this study was to estimate PC HCR from easily obtainable data and the impact of hospital bed size and distance. Methods: After IRB approval, each hospital's number of poisoned patients was estimated by a computerized search of a statewide hospital discharge database for discharge code(s) (ICD9-CM) indicating acute PO. HCR was estimated by dividing the PC consultations (tabulated from the PC's annual report) by hospitalized PO for each hospital for each yr. from 1994-6 and within distance and bed size strata. Overall HCR (total hospital PC consults/total hospitalized PO) was calculated for each yr. and 3 yr. combined. HCR [is greater than] 100% were set at 100%. Differences between strata means were analyzed by ANOVA with p [is less than] 0.05 (*). Results: Mean [+ or -] SD HCR for the 87 hospitals for the 3 consecutive yr. were 58 [+ or -] 0.34%*, 55 [+ or -] 0.32%* and 52 [+ or -] 0.32%, respectively, and 57 [+ or -] 0.31% for 3 yr. combined. The overall HCR for 3 yr. were 35%, 35% and 34%, respectively, and 35% for the 3 yr. combined. Mean HCR for distance strata ([is less than or equal to] 50, [is greater than] 50 but [is less than or equal to] 100, [is greater than] 100 mi. from PC) were 42%*, 58%* and 70%*, respectively. Mean HCR for the 4 bed size strata ([is greater than] 200, [is greater than] 100 but [is less than or equal to] 200, [is greater than] 50 but [is less than or equal to] 100, [is less than or equal to] 50 beds) were 32%*, 44%*, 68%* and 79%*, respectively. Conclusion: For 3 yr. combined, mean HCR was 57% and overall HCR was 35%. HCR was found to be directly proportional to distance from PC and inversely proportional to hospital bed size. PC HCR can be easily estimated in some cases from readily available data and is an important estimate of PC utilization in serious poisonings., Martin TG, Naef R, Robertson WO. Washington Poison Center, Seattle, [...]

Background: In 1980, Tso and Robertson determined that many physicians' handwritten prescriptions at our Children's Hospital were deemed illegible by separate judging panels of physicians, pharmacists, nurses and medical students. They called for remedial action to be imposed--but none followed! In 2000, our state legislature modified a proposal to make 'other than printed, typed or computer-generated prescriptions ... unprofessional conduct ...' subjecting the perpetrator to possible license revocation, to a law that simply mandated all prescriptions be legible--with a not-so-hidden message that no one could challenge their wisdom. We--and others--decided to do so. Method: As an obvious 'quality assurance process' requiring no Institutional Review Board approval, several pseudo-random samples of prescriptions already filled during the year 2000 were obtained with the cooperation of the Hospital's Pharmacy Department. Thirty prescriptions were arbitrarily classified 'customary'; 15 as 'difficult'. Volunteer judges of legibility were sought and obtained. All 10 members of each of the 4 panels proceeded to interpret 45 separate prescriptions for their 'legibility, possible legibility or illegibility.' All were timed with a stopwatch. Results: Among the sample of 30 customary prescriptions, the mean rates of illegibility for each of the ten-member panels were A) pharmacists = 4%, B) physicians = 2%, C) nurses = 5%, and D) medical students = 8%. Among the sample of 'difficult prescriptions' the comparable percentages were 23%, 12%, 20%, and 43%. For the 'difficult prescriptions' each of the 600 interpretations consumed a mean of 16.4 seconds, compared to 8 seconds for the others. Conclusions: Clearly, illegibility remains a problem. Remember: each of these prescriptions had, in fact, been filled! Would you bring your child to our hospital?, Kelso G, Robertson WO. Washington Poison Center, Seattle, [...]

Background: Poisoning (PO) epidemiology is essential in prioritizing PO research, treatment and prevention efforts. Our objective was to describe the epidemiology of hospitalizations for acute PO in Washington (WA) from 1987-96. Methods: After IRB approval, WA hospitalized PO were identified by a computerized search of a statewide hospital discharge database (CHARS) for cases with a ICD9-CM discharge code(s) indicating acute PO and descriptive analyses performed. Results: Mean yearly # and rate/100,000 (range) of WA hospitalized PO during the 10 yr. interval was 4,437 (4,278-4,596) and 88.2 (77.8-100.4), respectively. PO related E (intent) codes were identified in 81% of cases (most after 1988) with 61% intentional, 32% unintentional and 7% other. Males accounted for 40% and females for 60% of PO cases. Those aged 15-54 accounted for 72% overall with the 25-34 yo group having the greatest overall proportion (22%) and 15-19 yo group having the greatest overall rate (145). Mean length of stay (LOS) was 3.5 d with 40% of LOS [is less than or equal to] 1 d and 80% [is less than or equal to] 4 d. Discharge status indicated: home ([+ or -] assistance) 76%, transferred 19%, AMA 3% and died 2%. Mean hospital charge per PO case was $4,694 with mean charges trending upward and more than doubling over 10 yr. Primary payer was Medicare/Medicaid in 46.5%, third party 35.7%, self-pay/charity in 14.1% and other government program 3.7%. Of 145 hospitals, 20 accounted for 52.5% of PO cases. Conclusion: A wealth of PO-related epidemiologic knowledge may be derived through analysis of hospital discharge data., Martin TG, Kenny RJ, Robertson WO. University of Washington Medical Toxicology Consult Service, University of Washington & Washington Poison Center, Seattle, [...]

Background: A wealth of poisoning (PO)-related epidemiologic data is contained in hospital discharge datasets. Our dataset contains 1 E (intent) and 9 N (diagnosis) fields (ranked in order of importance) which may contain more than one PO ICD9-CM code/case. Our objective was to compare the numbers of cases identified by different definitions of hospitalized PO in the data from Washington (WA) State for 1987-96. Methods: After IRB approval, WA hospitalized PO were identified by a computerized search of a statewide hospital discharge database (CHARS) for cases with variable numbers of code fields indicating acute PO, then descriptive analyses was performed. Results: Use of the Ecode and the 1st Ncode ('primary' diagnostic), the first 2 Ncode or the first 3 Ncode fields identified 90.8%, 94.2% and 96.8%, respectively, of the total cases (44,375) identified using all 10 code fields. Broadening the definition to include the 4th to 9th Ncode fields only added an additional 3.2% of the total cases. Because of mixed drug PO, a total of 0, 1, 2 or 3 PO Ecodes were identified in 7,760, 35,833, 778, and 8 cases, respectively. Likewise, a total of 0, 1, 2, 3, 4, 5, 6, 7 or 8 PO Ncodes were identified in 2,514, 31,430, 7,610, 2,198, 493, 108, 15, 5 and 2 cases, respectively. Conclusion: When searching for cases most likely hospitalized because of PO, limiting the inclusion criteria to the Ecode and first 1-2 Ncode fields is recommended. When searching for all PO related hospitalizations, inclusions of all E & Ncode fields is recommended. However, the differences are not very great with either approach., Martin TG, Robertson WO. University of Washington Medical Toxicology Consult Service, University of Washington & Washington Poison Center, Seattle, [...]

Background: Clearly the information explosion is only getting more intense. At mid-century, the American Chemical Society's registry documented some 1.2 million chemical entities since the origins of mankind. Over the next 50 years, that number saw an exponential increase to greater than 19 million at the Millennium. How well are Poison Center staffs keeping up? We've initiated inquiries to find out. Method: Every Monday, the Washington Poison Center holds a teleconference for its distantly located Associate Medical Directors; it's also recorded for staff review. The prior week's unusual cases are discussed; new local happenings are identified via newspaper clippings and some 12-15 national news items and journal articles are highlighted-and then attached to the dictated minutes of the session for personal review. After discussion with the entire staff, we prepared a 20-item multiple choice memory-based examination for all staff to complete-including the administrative secretary--based on a pseudo-random item selection from some 60 topical reprints distributed over a 3-month period; we pre-tested the questions for clarity only. Results: Of the 35 total full- and part-time staff members, all except four completed the questionnaire. Interestingly, the mean percent of correct answers was 67%; and there was no evidence of the usually expected normal distribution curve. Overall, the staff seemed very enthusiastic about the exercise and were invigorated to hear that the administrative secretary actually had the third highest score! Conclusion: This 'exercise', though intended to be provocative, seemed to stimulate group collegiality. Moreover, it documented that 'memory exams' are most certainly relics of the past--because of information overload. No one would dream of tolerating a 30-35% error rate in medicine today; the aviation industry aspires to less than 0.1%. Our philosophic paradigm remains constant; access to answers rather than memory retention of information is the wave of the future., McMullin N, Robertson WO. Washington Poison Center, Seattle, [...]

Background: In November 1960, Done published his sentinel 'nomogram' observation based upon data from 29 children and 9 adults with acute salicylate (36) or oil of wintergreen (4) ingestions. It demonstrated that serum salicylate levels were predictive of clinical outcomes only when time since ingestion was factored into the predictive equation. In 1963, we confirmed his inferences in a sample of 102 children. In both instances, unfortunately, the assumption was made that absorption of the salicylate moiety took 6 hours. Even today, after 40 years, that assumption continues to be employed when one seeks to use Done's nomogram. It results in a delay in drawing initial salicylate levels till 6 hours has passed since ingestion. We decided to reexamine our 1963 data plus 50 additional cases occurring in that same year to determine the effect of using 4, rather than 6 hours, as the time delay required to achieve 'absorption' of the salicylate moiety-based upon current pharmacokinetic understanding of aspirin. Method: Quite simply, the slopes resultant from Done's regression equation to achieve his [S.sub.o] levels remain unchanged because they reflected only excretion rather than absorption. Consequently, the resultant regression lines were simply 'shifted' 2 hours to the left. Results: Not surprisingly, since the clinical groupings of outcome remained constant, the respective [S.sub.o] levels fell approximately 10% at the lower ranges to 7% at the higher ranges--in truth, both being clinically inconsequential. Conclusions: While these minor adjustments may help explain the small differences that occurred between the two prior studies, the consequences are, in fact, trivial. We see the resultant adjustment emphasizing no need to wait 6 hours, but rather relying on 4 hours after ingestion, to draw a representative blood sample just as is employed for the majority of other clinical poisonings., Hodge J, Robertson WO. Washington Poison Center, Seattle, [...]

Objective: Over the past two centuries, attempts to salvage orally poisoned patients have usually involved some process of 'decontamination'--e.g. emptying the stomach or curtailing absorption of poisons. Today, use of the nasogastric tube is at the bottom of the list of effective remedies. Induction of emesis with Syrup of Ipecac boomed in popularity in the early 1960s, but then declined with the 're-discovery' of activated charcoal by Holt in 1964. It burgeoned as promoted by members of the emerging specialty of Emergency Medicine in the 1970s and 80s and appears to have been cast in concrete by the release of 'expert-based guidelines' in 1997. Particularly over the last decade, more and more data support the contention that both liquid as well as many solid medications are rapidly absorbed so that time lapse till decontamination rather than its technique has emerged as the most significant contributor to the variance of treatment effectiveness. Often, charcoal fails to be administered for more than an hour after victims have arrived at hospital. We sought data to support or refute the validity of this concern. Method: Two studies were undertaken; the first (Plan A) was a community wide effort seeking data explicitly related to time lapses occurring until: A) recognition of a poisoning, B) response of 911 team, C) completion of trip to hospital, and D) successful administration of activated charcoal. The second (Plan B) involved a survey of Washington's 110+ hospitals with ED requesting data on delay times between arrival in the ED until completion of charcoal administration. Both studies were classified as 'Quality Assurance Investigations' thus necessitating neither consents nor Institutional Review Boards' attention. Results: Under Plan A, data from some 50 cases were collected and analyzed. In no instance had charcoal been administered in the field or during the ambulance transport. The anticipated 30-90 minute delay ensued after arrival. In contrast, Plan B's more than 60 responses revealed a mean of 46 minutes delay between arrival in hospital till completion of charcoal administration. Discussion: Recent publications starting with Wax & Cobaugh (1998) have also recorded significant delay times--e.g. 88, 91, 131 and 93 minutes respectively-before charcoal had been successfully administered after ED arrival. In contrast with patients suspected of myocardial infarctions or strokes, time lapse till treatment averages less than 5 minutes in many ED's. Conclusion: While proponents of activated charcoal are adamant in their advocacy position, evidence from existing literature and from our studies raise doubts about using charcoal in the real world. We feel the problem could be rapidly remedied with but a single multi-million dollar negligence award., Steinman S, Winter J, Robertson WO. Washington Poison Center, Seattle, Washington, [...]

To the Editor Formal investigation of drug errors began in the United States only after World War II. By the early 1960s, several hospitals had attempted to quantify their drug [...]

Background: 'Drug Imprinting' was first implemented by Eli Lilly and Company in 1962 for all its products. The state of Washington mandated the use of imprints on all prescription drugs in 1980 and for 'OTCs' in 1991. The FDA implemented federal requirements in 1995. Unfortunately, the FDA permitted the continued use of symbols, logotypes, and trademarks as code components, limiting the use of automated recognition systems, which we demonstrated in both 1992 and 1995. In December 1999, we sought a measure of our success in responding to phone inquiries seeking decoding of imprints. Method: Analyses of several week-long samples of phone inquiries were conducted, documenting imprinting calls, the staff's ability to respond with an identification, the information sources used, and the apparent reasons for any failure. Results: Surprisingly, in our first week's sample, we received a total of 666 decoding requests, which--projected for the year--amounted to more than 25,000 annual calls. A review of 1999 total data confirmed we had exceeded that number. Staff was able to reach an identification in 93.8%. Both uninterpretable symbols and absence of code listings contributed to the 36 failures. Conclusion: While we were pleased to achieve a greater than 90% success rate, we were overwhelmed by the number of inquiries and repeated our study on several subsequent week samples. Projecting our findings and our penetrance to the rest of the United States would suggest as many as 1.25 million possible calls costing poison centers as much as $25 million per year. Using either a touch-tone telephone or website response system could permit a totally automated response with enormous reduction in human costs. Neither solution is feasible absent elimination of symbols or logotypes, so as to permit an exclusively alpha-numeric code. Efforts are underway to achieve same., Marder S, Winkler T, Tadaki K, Bobbink S, Robertson WO. Washington Poison Center, Seattle, [...]

Background: On January 1, 1999, the Washington Poison Center implemented Toxicall; 6 months later we sought to measure its impact on time consumed by staff members for each of 3 missions--A) telephone interchange, B) information retrieval from other than Poisindex[R] and C) documentation, and to compare it with prior studies of our conventional paper-pencil system. We conducted previous 'time and motion' studies over the past decade, using random alarm devices (Devilbiss Electronics) and had data for comparative purposes. Method: Two investigators (DG and YG) developed a computer-based alarm system for both timing and station selection and for recording the observed events. Results: Over a 6-week period, 211 calls were analyzed; the percentage of time involved in each call was recorded (shown in Table) and compared to results from our 1993 study. An increase, rather than anticipated decrease, in documentation effort was observed ([is less than] 0.05), but staff participation in other activities than those itemized fell even more dramatically, suggesting increased staff efficiency. Percentage of Time Allocation Behavior Observed 1993 1999 [chi square] Phone Interchange 31.4 35.4 NS Info Retrieval 6.2 7.9 NS Documentation 24.4 33.4 Conclusion: We were disappointed to discover that documentation efforts consume so much time. We are working on solutions to that problem. Toxicall was successful in providing one nondebatable benefit; it finally eliminated illegibility of staff handwriting! Gopalan D, Gopalan Y, Robertson WO. Washington Poison Center, Seattle, WA, Gopalan D, Gopalan Y, Robertson WO. Washington Poison Center, Seattle, [...]

Introduction: Trichlorosilane and tetrachlorosilane are involved in the production of semiconductor grade silicons. This is the first report of critical injuries following exposure. Case Reports: Four male workers were injured by exposures from a ruptured pipe carrying 330 [degrees] F pressurized trichlorosilane and tetrachlorosilane with subsequent explosion and fire. All 4 were decontaminated at the scene and sustained a toxic inhalation, corneal burns and patchy partial and full thickness dermal burns. Case 1, a 26-year-old, and Case 2, a 55-year-old, experienced severe corneal burns, necrotic laryngotracheobronchitis, and pneumonia, which progressed to severe ARDS despite steroids. Case 1 also had posttraumatic glaucoma (intraocular pressure [congruent] 80 mmHg) resulting in retinal and corneal ischemia and expired on day 38. Case 2 also had hypotension requiring pressor support; acute renal failure, sepsis and atrial fibrillation and expired on day 16. He had a previous history of myocardial infarction. Case 3 was a 24-year-old with mild corneal burns, moderate respiratory insufficiency and laryngotracheobronchitis, which progressed to bronchiolitis obliterans; and was discharged moderately disabled on day 8. Pulmonary function tests 11 months later showed severe airflow obstruction, air trapping and mildly reduced diffusing capacity. Case 4 was a 29-year-old with mild corneal bums, mild respiratory insufficiency and oropharyngeal and laryngeal burns who was discharged on day 15. Pulmonary function tests 1 year later showed mild restrictive lung disease. Conclusions: Chlorosilanes react vigorously with water, releasing hydrogen chloride, which may also produce injury. These patients had persistent respiratory effects more severe than previously reported, and ocular findings not previously reported in the peer-reviewed medical literature., Martin TG, Burgess JL, Tadaki K, Robertson WO. University of Washington Medical Center, Washington Poison Center, Seattle, [...]

Objective: To study adverse outcomes in individuals exposed to hazardous materials. Methods: Individuals exposed during hazardous materials incidents were contacted to complete a questionnaire within 8-40 days, and medical records were reviewed when available. Logistic regression analysis adjusting for correlation using GEE was used to identify predictors of adverse outcome. Results: From 12/97 to 10/99, 87 incidents were reported. 202 (59%) of 339 subjects with contact information were surveyed. 51 (25%) subjects had persistent medical symptoms. 18 (9%) left work or school for [is greater than] 2 days. Medical records were available for 79 (66%) of 119 subjects evaluated in a health care facility. Medical treatment was reported in 46 (58%) and objective abnormalities in 57 (72%). For persistent symptoms, dermal exposures (OR 3.75, 95% CI 1.47-9.59), [is greater than or equal to] 3 alcoholic drinks/week (3.16, 1.13-8.80), and present or past use of psychiatric medications (2.68, 1.15-6.28) were significant predictors. For time loss, being divorced, widowed, or sepa rated (8.36, 1.40-50.1), asthmatic (4.92, 1.29-18.7), or having initial dermal symptoms (6.77, 1.34-34.2) were significant predictors. Of patients with medical records, those with preexisting hypertension (10.6, 1.82-61.3) were more likely to receive medical treatment or have objective medical findings, while those with inhalation exposures (0.17, 0.04-0.78) and those decontaminated at the scene (0.14, 0.03-0.69) were at reduced risk. Conclusions: Both incident and individual patient factors were associated with persistent symptoms, time loss, and medical treatment or objective medical findings., Burgess JL, Kovalchick DF, Lymp JF, Kyes KB, Robertson WO. University of Arizona, Tucson, AZ; University of Washington; Washington Poison Center, Seattle, [...]

Objectives: Currently, public opinion pollsters report that Americans fear pesticides far more than tobacco smoke--apparently even more than Europeans fear `Frankenfoods'. The question is, of course, `Do data from the last decade support such a phobia?' Methods: Acute morbidity and mortality data from pesticides were gathered from the annual reports of the American Association of Poison Control Centers for the last decade and compared with comparable data for carbon monoxide and ethylene glycol. In addition, data dealing with exposures were culled from the annual reports of the state of Washington's Pesticide Incident Reporting and Tracking Panel since 1989. Finally, national data dealing with chronic conditions in childhood were appraised on the assumption that detrimental effects of chemicals--were they to exist--would be reflected in chronic morbidity and mortality data. Results: Over the past decade, more than 595,000 total pesticide cases were reported to the AAPCC; among these there were 124 deaths, with 67% being classified as suicidal. Moreover, a total of only 14 deaths in children aged less than 10 were attributed to `pesticide poisoning'. In contrast, carbon monoxide accounted for some 130,000 cases, with 327 deaths, again with many suicidal efforts. Similarly, ethylene glycol's track record continues to burgeon with some 45,000 case reports with 104 deaths--more than 80% of which were related to suicide, but with only 1 death--a homicide--among 7,100 children. Review of chronic morbidity and mortality figures from the United States shows a continuing decline in incidence of both--save for the occurrence of what is classified as `asthma' and certain unusual forms of acute leukemia--wherein improved diagnostic accuracy serves as an enormous confounder. Conclusion: In the author's opinion, current data simply do not begin to explain in any way, shape, or form the US public's paranoia about pesticides. Conceivably, exaggerations and extrapolations from the `DDT fiasco' as popularized by Rachel Carson's `Silent Spring' in 1962 is etiologic. Perhaps our society is simply experiencing hesitancy in accepting `any and all synthetic chemicals' as it seeks to return to the `good old days'. Or conceivably our media have been more successful than might be expected in popularizing the heritage of organophosphate pesticides from their forebears of `nerve gases'--still available to terrorists on a worldwide basis. Personally, I would hypothesize that paranoia about genetically modified foods in the US is unlikely to achieve enough status to replace pesticides as the leading target of ridicule. But, candidly, I'd be optimistic that a media campaign alerting our population to the horrendous dangers of `aliens from outer space' might just succeed in removing the focus from pesticides. Robertson WO. Washington Poison Center, Seattle, Washington, USA

Objective: The past century has seen the initial recognition of clinical lead poisoning in childhood, the initiation of treatment efforts via chelation, the subsequent popularization of `sub-clinical lead poisoning' in toddlers as a significant cause of mental retardation, attempts to reduce or eliminate exposures to environmental lead by a variety of efforts, and call for `universal screening' of toddlers throughout the United States in 1991. As the century closes in the U.S., does the yield from current epidemiologic data support continued pursuit of universal screening--or has the purported epidemic of lead poisoning actually disappeared? Methods: Blood lead levels and environmental data have been gathered from the scientific literature and additional data have been developed within the state of Washington to attempt to answer the question posed. Results: In 1976-80, U.S. NHANES data revealed almost 90% of children age 5 years or less had blood lead levels greater than 10 [micro]g/dL. By 1990, however, with the elimination of leaded gasoline, atmospheric lead concentration had fallen to less than 7% of prior levels and only some 9% of comparable children's blood levels exceeded 10 [micro]g/dL. Moreover, recent randomized studies conducted in Washington and in Colorado in 1999 have shown the percentage of elevations of blood lead levels greater than 10 [micro]g/dL to have further declined to less than 0.9%--i.e. a 25-year reduction from 90% to less than 1% elevations. Conclusion: Accepting the cost-benefit modeling strategy as published by Berwick and Komeroff[1] for screening to prove effective, the target population has to have more than 6.7% of its members with elevated blood leads. Clearly, with current blood lead level data almost 10 times below such a frequency, it is clearly no longer justified to continue universal testing of toddlers for sub-clinical lead poisoning. One might even go so far as to accuse proponents of universal screening of championing child abuse for their own gratification--much as has been done in dealing with proponents of routine circumcision by critics of that barbaric procedure. References: [1] Berwick DM, Komaroff AL. Cost effectiveness of lead screening. N Engl J Med 1982; 306:1392-1398. Robertson WO. Washington Poison Center, Seattle, Washington, USA M, Kupfersch

Background: Foxglove is a common plant both in the wild as well as cultivated for decorative use in northern climates. The leaves can reach 3 feet in length. Digitalis is contained both in the leaves and in the stems. Case Report: A 46-year-old Asian woman without any previous cardiac history presented to an emergency department (ED) after ingesting 4 large foxglove leaves 4 hours previously. (She had mistaken the plant for comfrey leaves intended for herbal use.) She had a sudden onset of nausea, lethargy, dizziness, and weakness and came into the ED. After finding notable bradycardia she was admitted for observation and continued to have nausea and vomiting. Treated with [O.sub.2], IV fluids, and 12.5 mg of promethazine for nausea, her EKG showed sinus and junctional bradycardia with intermittent second degree AV block. Her continuously monitored heart rate transiently dipped into the 30s. Her digoxin level was 0.8 ng/mL (normal levels for patients on digitalis = 1.9 or less) and her potassium was 4.5 mEq/L. While the nausea resolved shortly, junctional rhythms and a second degree block persisted. She was then given 2 vials of Digibind--approximately 24 hours after her original ingestion. Subsequently her digoxin level remained 0.8 ng/mL. When her bradycardia and AV block persisted, she was given 2 additional vials of Digibind some 48 hours after her original ingestion without notable effect. Two days later she was, however, discharged with transient AV block, but was ambulating without symptoms. Conclusion: Rarely are accidental plant ingestions of serious consequence--unless 'a meal is made of the plant.' In the case of foxglove ingestion, the measured digitalis level does not necessarily reflect the all cardiac alkaloids that are present in serum., Porter R, Schultz D, Robertson WO. Washington Poison Center, Seattle, [...]

Background: In the late '80s, our poison center initiated its 'Critical Incident Studies' (CIS) to provide yet another needs assessment for CE functions. As we reported in 1995, the process proved effective. We sought to reassess its value as we adopted Toxicall[R]-electronic documentation. Method: At the end of each shift, each staff member was asked to note what-if any-'gnawing question or concern' remained with him or her. Group totals were tallied, categorized and carefully reviewed. Results: The 222 responses collected pre- and post-Toxicall were compared to prior categorizations as follows:, 1987 1994 1997 % (N = 330) % (N = 93) % (N = 222) 1. Treatment Issues 46 73 26 2. Administrative Matters 25 16 35 3. Facility Problems [...]

Objective: To determine a simple and cost-effective way for a regional poison center's public education department to reach a state population with information concerning National Poison Prevention Week and year-round poison center services. Method: We designed four bookmarks each with a different poison prevention message. At the beginning of February we distributed 200 bookmarks, along with one National Poison Prevention Week poster to each public library in the state. In early May we mailed each library a questionnaire to (1) determine how many distributed and posted our materials, and (2) obtain feedback on the librarians' perceptions of the project's effectiveness. Results: Fifty-one percent (167) of 326 libraries responded to our questionnaire. Of the respondents, 94% (157) reported the bookmarks had been distributed to patrons during National Poison Prevention Week. Ninety-one percent (153) felt the bookmarks were an effective way of letting people know about both the poison center and National Poison Prevention Week. Forty-three percent (72) thought too many bookmarks had been mailed. Forty-four percent (74) thought the number of bookmarks had been sufficient and 8% (14) thought the number had been too small. Sixty-three percent (106) had displayed the poster on one of their bulletin boards and 28% (47) had not. Ninety-seven percent (163) noted that they would like to receive similar materials in the future and 3% (4) indicated they would not. Based on our daily statistics, there had been an actual increase in the number of calls to the poison center during the month of March, including more than the expected number of requests to our public education department for materials and information. Conclusion: Distribution of bookmarks via the public library system appeared to be a successful way to both educate and inform the public about National Poison Prevention Week and the availability of our statewide poison center and its services., Cropley J, Gibson J, Christoff D, Bobbink S, Robertson WO. Washington Poison Center, Seattle, [...]

Background: For centuries, silver--as with gold--has been endowed with therapeutic benefits. Fortunately, in small amounts, it seems to kill almost no one but many persistent users end up with a [...]

Background: Back in the 1960's, 'medication mix ups' or 'drug errors' first surfaced as risks to our patients' well being. Far too frequent use of abbreviations were crucial contributors to erroneous interpretations of both written and as well as verbal orders. Does 'DPT' mean 'Demerol, Phenergan and Thorazine' or 'Diphtheria, Pertussis and Tetanus'? By the 1970's, the Joint Commission of Accreditation of Hospitals moved to require each hospital to develop its own unique list of approved abbreviations for exclusive use on their premises. Misinterpretations of their meaning continued to run amuck. Between 1972 and 1997, we surveyed our medical staff on the written records of their practices 8 different times. Repeatedly, barely 50% of the 'used and approved' abbreviations were correctly interpreted and usually staff was no better than 50:50 in identifying which had been approved. Not unexpectedly, no corrective action whatsoever was undertaken. Spurred on by the Institute of Medicine's 'To Err is Human,' we decided to re-survey our target audiences again this year. Method: A 15 item form listing only approved abbreviations was widely distributed among our staffs, along with pleas for completion. Results: Among the sample of 1500 interpretations we selected for analysis, this time just short of 55% of the respondents were correct in their interpretations of the 'approved abbreviations'. Poison Center staff were not significantly better- or worse. D/W (Distilled/Water) was 'misinterpreted' as Dextrose/Water by 95%-95%! of the respondents. And, WA (Wide Awake/With Assistance) was also erroneously interpreted as Washington by 99%. In contrast, B.S. (Bowel Sounds/Breath Sounds) was correctly interpreted by 81% of respondents although 'Logan' s Medical Abbreviations' lists 30 other approved meanings--admittedly failing to include the most common usage b--- s---!. Conclusion: Abbreviations are alive, well and thriving--and still producing errors!, Henry P, Robertson WO. Washington Poison Center, Seattle, WA. [...]