Preventing perioperative adverse drug reactions - Home Study Program

(1) define the physiological mechanisms for medication toxicity, (2) describe potentially preventable adverse drug reactions (ADRs), (3) explain nursing guidelines to prevent ADRs, and (4) identify patient guidelines to prevent ADRs.

This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements.

For years, patients reported their perioperative medication-related fears as failure to wake up, allergic reactions, and prolonged paralysis from spinal anesthesia. The Institute of Medicine's controversial report, To Err is Human: Building a Safer Health System, may have changed how patients consider safety issues related to health care. (1) The hospitalized patient's number one fear now is receiving the wrong medication. The second greatest fear is being given two or more medications that interact with one another in a negative way. (2)

Nurses should heighten vigilance, not only in response to these patient concerns, but also in recognition of the following risks inherent in surgical, endoscopic, and special procedures.

* Medications often are given intravascularly or directly into an organ, quickly triggering an event.

* Procurement and administration of medications given during procedures are out of the pharmacist's realm of oversight.

* Patients often are sedated or unconscious, which prevents accurate reporting of known medication allergies and reactions and reporting of any current symptoms of interaction as they occur.

* Often health care practitioners are unfamiliar with newer classes of medications, many of which only recently have entered postmarket surveillance.

* There is a renewed interest and resurgence in use of older medications that have been known to have caused critical interactions in the past.

* Medications are administered to high-risk and chronically ill patients frequently and routinely during procedures, sometimes with little or no tailoring of dosage.

* Patients have more medication exposures than previous generations because of longer life spans and the advent of new procedures.

It has been reported that up to 30% of hospitalized patients experience an adverse drug reaction (ADR). (3) If an important goal is to prevent adverse outcomes, nurses should do more than ask a patient what medication allergies he or she may have. It is essential that all health care practitioners take comprehensive medication histories, remain constantly vigilant for ADR, and recognize inherently dangerous patient/medication combinations.

An ADR is any toxic or poisonous effect experienced after exposure to a medication in the dose and intended manner for prophylaxis, diagnosis, or treatment. Medications usually are considered the offending agents, but adjunctive agents, such as latex products, fibrin glue, and vascular grafts, also can cause unwanted effects, including anaphylaxis. An adverse drug event has a broader definition and includes causes of injury that are not from medication toxicity alone. Errors in prescribing, dispensing, administering, monitoring, and noncompliance or medication abuse all are events that interfere with optimal patient care and increase patient cost. (4)

PHYSIOLOGICAL MECHANISMS FOR TOXICITY

Predictability and mechanism of action are both methods of classifying medication toxicity. Predictable toxicity often is dose-related and largely expected, as in the relationship of insulin to hypoglycemia. Of greater concern to health care practitioners is unpredictable and unanticipated toxicity. Predictable and anticipated adverse reactions account for 70% to 80% of all ADRs. Only 20% to 30% of adverse reactions are unpredictable. (5) In addition to classifying medication toxicity by predictability, it also can be categorized by pharmacological, biochemical, or immunological mechanisms of toxicity. (6)