Pulmonary arterial hypertension (PAH) is a rare disease characterized by vasoconstriction

Feature Safety Recommendations for Administering Intravenous Prostacyclins in the Hospital MARTHA S. KINGMAN, DNP, FNP-C KELLY CHIN, MD Prostacyclins are a high-risk category of continuous intravenous infusions increasingly used in hospitals to treat advanced pulmonary arterial hypertension, a rare condition characterized by vasoconstriction and vascular proliferation of the pulmonary arteries. Prostacyclins are given in doses of nanograms per kilogram per minute and have a narrow therapeutic dosing range for each patient. Sudden increases or decreases in dose can be life threatening. Previous studies revealed errors in the administration of these high-risk infusions, which in some instances led to serious adverse events, including death. The literature was reviewed for safety measures in administration of high-risk intravenous medications and input was obtained from leading experts in pulmonary arterial hypertension to create a set of safety recommendations for infusion of prostacyclins. (Critical Care Nurse. 2013;33[5]:32-34,36-41) Pulmonary arterial hypertension (PAH) is a rare disease characterized by vasoconstriction and proliferation of the small pulmonary arteries, changes that eventually lead to right-sided heart failure and death in most patients who have the disease. 1 When PAH is diagnosed early in the course of the disease, initial treatment usually consists of oral therapy, including phosphodiesterase type 5 inhibitors and endothelin receptor antagonists. 2 Intravenous epoprostenol sodium (Flolan), epoprostenol for injection (Veletri), and treprostinil (Remodulin) are intravenous prostacyclins given as continuous infusions in the most advanced cases of PAH. 1 Prostacyclins are potent vasodilators, inhibit platelet activation, and have antiproliferative effects on smooth muscle and intimal cells. 3 Intravenous prostacyclins are expensive and require a comprehensive insurance approval process. Once approved, the drugs are commonly started in the hospital at a dose of 1.25 to 2 ng/kg per minute via a dedicated central catheter, and the dose is increased according to the signs and symptoms of PAH CNE Continuing Nursing Education This article has been designated for CNE credit. A closed-book, multiple-choice examination follows this article, which tests your knowledge of the following objectives: 1. Distinguish between adverse effects of prostacyclins and symptoms of pulmonary artery hypertension 2. Summarize 4 approaches to prevent errors associated with high-risk medications 3. Describe 3 safety recommendations that reduce error during prostacyclin administration 2013 American Association of Critical-Care Nurses doi: http://dx.doi.org/10.4037/ccn2013608 32 CriticalCareNurse Vol 33, No. 5, OCTOBER 2013 www.ccnonline.org

and the side effects of the prostacyclin being administered. Dosing is generally highly individualized according to the severity of the disease and how well patients are able to tolerate the side effects of the drug. Common side effects include headache, jaw pain, flushing, nausea, diarrhea, rash, and pain in the extremities. 3 Signs and symptoms of PAH include shortness of breath, chest pain, palpitations, edema in the lower extremities, and syncope. 2 Nurses caring for PAH patients should be able to recognize the differences between the side effects of prostacyclins and the signs and symptoms of the disease (see Table). Prostacyclins have a narrow therapeutic window, and sudden increases or decreases in dose can lead to life-threatening consequences. 8 For this reason, safety measures should be in place to prevent errors when these high-risk infusions are administered. According to the Agency for Healthcare Research and Quality, 9 adverse drug events result in more than 770 000 injuries and deaths each year and cost up to $5.6 million per hospital. In one survey, 10 nurses reported making 2 to 5 errors in administration of intravenous medications during a 14-day period in the intensive care unit (ICU). In a study by Rothschild et al, 11 serious medical errors that could potentially cause harm or actually did cause harm were common in critical care units. The daily rate was 0.8 adverse events and 1.5 serious errors for a 10-bed critical care unit. This finding was consistent with the results of other ICU studies. 12,13 Medication errors most likely to result in serious outcomes include intravenous medications; medications given in specialty areas, such as ICUs; and medications with complex dosing regimens. 14,15 Intravenous prostacyclins meet all of these criteria. Administration of intravenous prostacyclins to inpatients can be challenging, because even at PAH centers, typically only a few patients are receiving an intravenous Authors Martha S. Kingman is a nurse practitioner in the pulmonary hypertension program at University of Texas Southwestern Medical Center, Dallas, Texas. Kelly Chin is the director of the pulmonary hypertension program at University of Texas Southwestern Medical Center at Dallas. Corresponding author: Martha S. Kingman, DNP, FNP-C, University of Texas Southwestern Medical Center at Dallas, 5939 Harry Hines Blvd, Suite 600, Dallas, TX 75390 (e-mail: martha.kingman@utsouthwestern.edu). To purchase electronic or print reprints, contact the American Association of Critical- Care Nurses, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints@aacn.org. Table Adverse effects of prostacyclin versus indications of pulmonary artery hypertension Adverse effects of prostacyclin a Headache Jaw pain Nausea/Vomiting Diarrhea Extremity pain Flushing Thrombocytopenia Indications of pulmonary artery hypertension b Dyspnea Fatigue Chest pain Palpitations Lower extremity edema Ascites Syncope a Based on information from package inserts for Remodulin, 4 Veletri, 5 and Flolan. 6 b Based on information from Elliott et al. 7 prostacyclin in the hospital at any time. Many pharmacists, nurses, and even physicians may have had limited experience with both the medications and the ambulatory infusion pumps. In a recent national survey, 16 68% of survey respondents reported serious or potentially serious errors in administration of intravenous prostacyclins in their hospitals. The most common errors (reported by 25%) included incorrect cassette placed in the pump, inaccurate pump programming, errant drug dosing, and inadvertent cessation of the pump. Nine errors, all at different centers, were thought to have contributed to a patient s death. Currently, no safety guidelines are available for administration of intravenous prostacyclins in the hospital. We reviewed the literature on ways in which pharmacists, nurses, use of technology, and even patients can play a role in reducing errors in administration of high-risk intravenous medications. Because of the lack of published research on errors associated with administration of prostacyclins, we obtained input from PAH experts in the Scientific Leadership Council and the Pulmonary Hypertension Professional Network, committees of the Pulmonary Hypertension Association. Literature on Prevention of Errors Associated With High-Risk Medications Pharmacy Interventions Removing high-risk medications from easy accessibility on nursing units can reduce errors. Such a reduction in errors was shown most impressively with potassium chloride, and making accessibility more difficult has also www.ccnonline.org CriticalCareNurse Vol 33, No. 5, OCTOBER 2013 33

been effective with other high-risk medications. 17 For medications that must be stored on the nursing unit, deliberate choices about storage location can be part of an overall safety strategy, particularly with products that look alike or have names that sound alike. Further, unique labels or other distinctions, such as tall-man lettering (ie, writing part of a drug s name in uppercase or capital letters), may help reduce medication mix-ups. 18,19 Adding a pharmacist to hospital units can also reduce errors, particularly in high-risk locations such as the ICU. 20 Nursing Interventions Nurses perceive that operator errors are related, at least partly, to distraction or exhaustion. 21,22 The results of several studies support these ideas: more frequent interruptions are associated with more errors, 23 and having more nurses on staff is associated with fewer errors. 24 Use of signage and checklists may minimize distractions during critical phases of administration and may reduce errors overall. 25 For higher risk medications, having a second nurse or pharmacist provide a double check on the medication may also be beneficial. 17,26 Skill level of nurses may also be important; nursing units with more professional Physically separating epoprostenol for nurses on staff injection, epoprostenol sodium, and rather than treprostinil on nursing units should also caregivers be considered. with less than a nursing degree also have lower error rates. 27 In contrast, short-term educational programs to reduce errors are not always effective, as shown in 2 studies 28,29 of computer-based education to prevent errors. On the other hand, Ford et al 30 reported a significant reduction in errors after a simulation intervention (P<.001) but not after conventional didactic lecturing. Use of Technology Use of smart pumps may reduce medication errors. For example, use of a programmable pump with programming such as the Guardrails Safety Software (Alaris Medical Systems Inc) allows parameters to be set for frequently used intravenous medications so that a warning occurs if a nurse attempts to administer a dose or use a rate that is outside set parameters. In one study, 31 this practice considerably reduced error rates. However, in another study, 32 rates of medication errors did not differ between conventional administration and administration via a smart pump. The lack of difference was attributed, in part, to frequent overrides of the smart pump and to bypassing the medication library altogether. Bar coding is another option that may reduce errors; at one center, this option resulted in reductions of more than 50%. 33 However, although the nurses who used a bar code system thought that the system was safe, concerns have been raised about the efficiency of the system, especially in emergency situations. 34 Patient Interventions Self-medication is used in some settings as a way to decrease medication errors. In a 6-month study 35 of 220 patients who administered their own regular oral medications, no medication errors occurred. According to a study by Nassar et al, 36 when hospitals have established policies on inpatients use of insulin pumps, most patients can safely keep using an insulin pump during hospitalization. Currently, no studies have been done on how having patients self-administer their own intravenous therapies affects medication errors. Recommendations for Safety Measures for Administration of Prostacyclins Literature on safety practices for intravenous administration of prostacyclins is limited. One article 37 outlining policies for administration of subcutaneous treprostinil has been published, but no safety guidelines for the administration of intravenous prostacyclins are available. In a previous study, 16 many errors in the administration of intravenous prostacyclin occurred. These findings suggest that prostacyclin infusion therapy is problematic and that an opportunity exists to improve safety practices for administration of this medication. Because of the limited data on administration of prostacyclin to inpatients, this set of safety recommendations incorporates strategies that have been beneficial in the administration of other high-risk intravenous medications. Furthermore, expert opinion from experienced PAH nurses and physicians was obtained and helped form this initial set of recommendations. The recommendations (see Appendix) are intended to be used as a framework in developing individual policies on administration of prostacyclins. Several of the generic safety measures recommended are straightforward, such as ensuring adequate staffing levels, using a high percentage of professional nurses, and limiting potential interruptions while 34 CriticalCareNurse Vol 33, No. 5, OCTOBER 2013 www.ccnonline.org

This document is not intended to supersede individual hospital policies. The intent of the document is to suggest some safety measures that have been helpful in other facilities that treat pulmonary hypertension and with other high-risk intravenous medications. Recommendations without references are the result of the findings from a national telephone and national electronic survey of 97 pulmonary hypertension centers by Kingman et al 12 (2009) and input from members of the Pulmonary Hypertension Association. I. Pharmacy Considerations Pharmacists presence in the intensive care unit has been shown to reduce medication errors, 14 and their presence should be considered where intravenous (IV) prostacyclin patients are admitted. It is strongly recommended that each facility develop clear, concise, standardized order sets for each of the prostacyclin infusions used in the inpatient setting. Require mandatory education and competencies on prostacyclins for pharmacists and technicians, including mixing, dosing, labeling, and storage. Use of Backup Cassettes or Bags Decide whether backup IV bags (or cassettes) of intravenous epoprostenol sodium (Flolan) or epoprostenol for injection (Veletri) will be kept on the nursing unit. Consider limiting the presence of backup prostacyclin on nursing units. Removal of high-risk IV medications from nursing units has been shown to reduce IV medication errors. 11 Because of the short half-life of Flolan and of Veletri, in order to provide emergency accessibility, storage on the nursing unit is desirable. Because of the longer half-life of treprostinil (Remodulin), consider not keeping backup Remodulin cassettes or bags on the nursing unit unless they can be kept in a secure location, and unique to the patient, such as a medication-dispensing system. If Remodulin must be kept on the nursing unit, and it does not fit in the medication dispensing system, do not store it in the refrigerator with Flolan. Remodulin does not require refrigeration and having numerous cassettes in 1 place increases the opportunity for a mix-up. In order to avoid mix-ups among look-alike drugs, if prostacyclin backup cassettes or bags are kept on the nursing unit, physically separate Flolan, Veletri, and Remodulin. Do not change dosing weight unless instructed to do so by the pulmonary artery hypertension team. Medication Preparation Remodulin comes in several concentrations. The recommendation is to match the concentration used by the patient at home in order to avoid potential calculation errors when the patient is discharged and returns to his or her usual concentration. Remodulin is available in multiple concentrations and can be purchased by the hospital pharmacy on a consignment-type basis and then paid for only if used. Contact the pulmonary hypertension physician s office or the patient s specialty pharmacy when the patient is admitted to obtain the patient s dose, dosing weight, concentration, and pump rate. Confirm with the patient that this information is correct and that the pump is running at the correct rate. If a titration schedule exists, obtain a copy and send it with the patient to the nursing unit; post a copy in the room next to the patient s bed, as well as in the medication administration record. Double check all calculations for concentration and infusion rate with a second nurse. Ensure that pharmacy labels are easy to read, including name, date, concentration, and pump rate. Ensure that all information is clearly stated in the medication administration record, including the time for the next cassette change and whether ice packs are required. If using cassettes, consider using a different color cassette, or a different color or type of label, for Remodulin, Veletri, and Flolan in order to prevent mix-ups. Miscellaneous If patients are using hospital pumps, consider software pump technology that minimizes the possibility of entering wrong rates. 25 To avoid confusion between the 2 epoprostenol products, consider using brand names of Flolan and Veletri, rather than epoprostenol, on the medication administration record, labels, and orders. Consider using the same diluent as Accredo specialty pharmacy uses to mix Veletri, in order to keep the process the same in the hospital (either physiological saline or sterile water). Whatever diluent is chosen, it should be physically separated in the pharmacy from the Flolan diluent. II. Nursing Unit Considerations Upon Admission Document pump type, concentration and dose of prostacyclin, location of catheter, and last dressing change. If a pump is changed to a hospital pump or a change is made in concentration, the change should be clearly documented. Continued Appendix Safety recommendations for administering intravenous prostacyclins in the hospital.

Consider placing a sign over the head of the bed stating Flolan, Veletri, or Remodulin infusion. Place markers on the Flolan, Veletri, or Remodulin tubing near connection sites stating Do Not Flush and Dedicated Flolan/Veletri/Remodulin line. A second nurse should sign off whenever a new cassette or bag is placed, or whenever a dose change is made. 10 This practice can be made a requirement in some electronic medical record systems. Avoid interruptions of nurses when they are administering prostacyclins. Studies 17,19 have shown a high correlation between interruptions and intravenous medication errors. At the beginning of each shift, document that the pump is running correctly and at a rate that matches the order on the medication administration record. Include patients in the medication administration process to the fullest extent possible. They have been highly trained in administration of their prostacyclin, especially when they are still using their home infusion pumps. 29 Ask the patient or the patient s caregiver to confirm name, concentration, dose, and pump rate at each cassette or bag change and whenever a rate change is made. Ensure that nursing staff understand when to use ice packs: Flolan requires ice packs if more than 8-hour bag/cassette is used. Veletri and Remodulin are stable at room temperature. Whenever a question arises about pump operation, the nurse should telephone the specialty pharmacy. The number can be found on all home infusion pumps. Flushing of the dedicated prostacyclin catheter was the most commonly reported error in the survey by Kingman et al. 16 The prostacyclin tubing should never be flushed, and no other medications should be coadministered. III. Hospital Administrative Considerations Decide whether patients will keep using their home infusion pumps or switched to using hospital pumps. Determine which nursing units may initiate prostacyclin therapy and which units may care for patients being treated with a prostacyclin. If magnetic resonance imaging (MRI) is needed, a plan should be in place for how this will be accomplished for patients using home infusion pumps. Additional tubing may be needed in order for the pump to be placed outside the MRI room, or the infusion may be changed to an MRI-compatible pump. Consider higher staffing levels and a higher percentage of professional nurses, because these factors correlate with lower error rates. 18,21 Consider bar-coding systems; their use may reduce errors. 27 Conduct regular pump training for all nurses on units where pulmonary hypertension patients are likely to be admitted. This training may be provided in conjunction with specialty pharmacies, particularly when home infusion pumps are used in the hospital. Training should include operation of the CADD Legacy pump and the CADD MS-3 pump. If the KRONO-5 pump is used for miniaturization, then training about this device should be included. At a minimum, nurses should be comfortable with changing the pump rate and priming the tubing. If the hospital has a rapid response team, the team members should also be trained as experts in the use of the home infusion pumps and be familiar with prostacyclin infusions. Appendix Continued these infusions are being infused. Additionally, because intravenous prostacyclins are nearly identical in appearance, an effort by the pharmacist to distinguish one prostacyclin from another is recommended. Options include using different fonts on the labels and using different color cassettes for each prostacyclin. Physically separating epoprostenol for injection, epoprostenol sodium, and treprostinil on nursing units should also be considered. When available, the use of bar coding could further reduce errors involving look-alike medications. 31 Other recommended safety strategies have not been studied but are based on expert opinion from members of the Scientific Leadership Council and the Pulmonary Hypertension Professional Network. Until further data are obtained, each hospital will have to determine its own best practices. One decision hospitals must make is whether or not admitted patients can continue using their home infusion pump or must be switched to using a hospital pump. Continuing use of a home pump will avoid risks related to the need to program a separate infusion pump, a change that typically requires a mathematical calculation because ambulatory pumps infuse in milliliters per 24 hours, whereas hospital pumps infuse in milliliters per hour. However, nurses familiarity with a patient s home pump will be lower than their familiarity with a hospital pump. In the survey 16 results published in 2009, differences in error frequency between the 2 approaches were not significant. In addition, hospitals www.ccnonline.org CriticalCareNurse Vol 33, No. 5, OCTOBER 2013 37

will have to make a decision about storage of backup cassettes, which can be kept either on the nursing unit or in the pharmacy. Because of the short half-life of epoprostenol, keeping backup cassettes readily available for emergent situations seems sensible, and patients are accustomed to having backup cassettes nearby at home. However, errors related to mix-ups in cassettes or intravenous bags may be more common if multiple backup cassettes for different patients are kept on the nursing unit. Treprostinil has a longer half-life Patients should be included in the than administration of intravenous prostacyclin epoprostenol, if they have been highly trained. so keeping backup cassettes of treprostinil in the pharmacy may be reasonable. This practice will decrease the number of cassettes on the nursing unit and thus lessen the opportunity for placement of a cassette intended for another patient. Involving patients in the process of administering medications can reduce the number of errors in settings other than the ICU. 35 Patients receiving intravenous prostacyclin infusions have typically had extensive training and have become experts on administration of the drug; they should be included in the administration of the prostacyclin to the fullest extent possible. If a patient or one of the patient s family members cannot assist in troubleshooting problems with prostacyclin administration, the patient s nurses should be trained to call the telephone number of the specialty pharmacy, which is listed on all ambulatory infusion pumps. Nurses who will be following these safety recommendations while caring for PAH patients should first undergo comprehensive training and then at least annual training. Training should include hands-on use of ambulatory infusion pumps and a review of the safety guidelines. The recommendations should be incorporated into a nursing policy to formalize the practices. Compliance with the recommendations, as well as number and severity of prostacyclin errors, should be routinely monitored to uncover any areas of concern. Nurses should be assured that the purpose of reporting errors is to reveal opportunities for improvement and should not be punitive. Conclusion Previous findings have suggested that prostacyclin infusion therapy is problematic and that an opportunity exists to reduce the number of medication errors associated with this therapy. Safety measures for other high-risk intravenous medications may be applicable to administration of prostacyclins, and an initial set of safety recommendations is offered. Of note, many of these safety recommendations are based on the results of qualitative research, including surveys and expert interviews. However, when possible, the recommendations are evidence based, as adapted from studies of administration of other high-risk medications. Few medication safety practices have been studied in clinical trials, 20 and thus even the most basic recommendations are generally based on quality improvement studies and other observational studies. Further, whether or not data on other high-risk intravenous medications can be extrapolated to the administration of prostacyclins is unclear. The recommendations in the Appendix were reviewed by the Pulmonary Hypertension Association, a patient-provider collaborative organization that advocates for patients with pulmonary hypertension, and have been presented in the Online University of the Pulmonary Hypertension Association. Studies are needed to determine the true impact of formal safety measures in patients receiving intravenous prostacyclins. Because no safety recommendations currently are available for inpatient use of prostacyclin medications, our recommendations can be a starting point for hospitals in developing prostacyclin policies. Hospitals should monitor and review all prostacyclin errors to identify compliance with safety recommendations and direct continued quality improvement. CCN Acknowledgments The authors thank Dr Sonja Bartolome for her assistance in editing the manuscript. Financial Disclosures Dr Kingman is a member of speaker bureaus and advisory boards for Actelion Inc, Gilead, and United Therapeutics Corp. Dr Chin oversees research grants to University of Texas Southwestern Medical Center at Dallas from Actelion Inc, Bayer, Gilead, GlaxoSmithKline, Novartis, United Therapeutics, GeNO LLC, and the National Institutes of Health. She is on advisory boards for Actelion, Gilead, and Bayer. Now that you ve read the article, create or contribute to an online discussion about this topic using eletters. Just visit www.ccnonline.org and select the article you want to comment on. In the full-text or PDF view of the article, click Responses in the middle column and then Submit a response. To learn more about caring for patients with pulmonary arterial hypertension, read Inhaled Treprostinil for the Treatment of Pulmonary Arterial Hypertension by Poms and Kingman in Critical Care Nurse, December 2011;31(6):e1-e10. Available at www.ccnonline.org 38 CriticalCareNurse Vol 33, No. 5, OCTOBER 2013 www.ccnonline.org

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CCN Fast Facts CriticalCareNurse The journal for high acuity, progressive, and critical care nursing Safety Recommendations for Administering Intravenous Prostacyclins in the Hospital Facts Prostacyclins are a high-risk category of continuous intravenous infusions increasingly used in hospitals to treat advanced pulmonary arterial hypertension, a rare condition characterized by vasoconstriction and vascular proliferation of the pulmonary arteries. Prostacyclins are given in doses of nanograms per kilogram per minute and have a narrow therapeutic dosing range for each patient. Common side effects include headache, jaw pain, flushing, nausea, diarrhea, rash, and pain in the extremities. Signs and symptoms of pulmonary arterial hypertension include shortness of breath, chest pain, palpitations, edema in the lower extremities, and syncope. Nurses caring for pulmonary arterial hypertension patients should be able to recognize the differences between the side effects of prostacyclins and the signs and symptoms of the disease (see Table). Prostacyclins have a narrow therapeutic window, and sudden increases or decreases in dose can lead to life-threatening consequences. For this reason, safety measures should be in place to prevent errors when these high-risk infusions are administered. Table Adverse effects of prostacyclin vs indications of pulmonary artery hypertension Adverse effects of prostacyclin a Headache Jaw pain Nausea/vomiting Diarrhea Extremity pain Flushing Thrombocytopenia a See full article for source material. Indications of pulmonary artery hypertension a Dyspnea Fatigue Chest pain Palpitations Lower extremity edema Ascites Syncope Pharmacy Interventions Remove high-risk medications from easy accessibility on nursing units. For medications that must be stored on the unit, be deliberate about storage location, particularly with products that look alike or have names that sound alike. Use unique labels or other distinctions to help reduce medication mix-ups. Add a pharmacist to a hospital unit like the ICU. Nursing Interventions Use signage and checklists to minimize distractions during critical phases of administration. For higher risk medications, have a second nurse or pharmacist provide a double-check on the medication. The skill level of nurses may also be important; nursing units with more professional nurses on staff rather than caregivers with less than a nursing degree also have lower error rates. Use of Technology Use smart pumps like a programmable pump that allows parameters to be set for frequently used intravenous medications so that a warning occurs if a nurse attempts to administer a dose or use a rate that is outside set parameters. Bar coding is another option, but concerns have been raised about the efficiency of the system, especially in emergency situations. Patient Interventions Self-medication is used in some settings as a way to decrease medication errors. Currently, no studies have been done on how having patients self-administer their own intravenous therapies affects medication errors. CCN Kingman MS, Chin K. Safety Recommendations for Administering Intravenous Prostacyclins in the Hospital. Critical Care Nurse. 2013;33(5):32-34,36-41. 40 CriticalCareNurse Vol 33, No. 5, OCTOBER 2013 www.ccnonline.org

CNE Test Test ID C1352: Safety Recommendations for Administering Intravenous Prostacyclins in the Hospital Learning objectives: 1. Distinguish between adverse effects of prostacyclins and symptoms of pulmonary artery hypertension 2. Summarize 4 approaches to prevent errors associated with high-risk medications 3. Describe 3 safety recommendations that reduce error during prostacyclin administration 1. Which of the following side effects is associated with adverse effects of intravenous (IV) prostacyclin therapy? a. Difficulty breathing b. Chest pain c. Jaw pain d. Lower extremity edema 2. Which of the following is true about IV prostacyclin infusions? a. Require small adjustments in dosing to maintain a narrow therapeutic range b. Produce pronounced vasodilation and hypotension c. Have a broad therapeutic range that can tolerate large increases and decreases in dosing d. Can lead to life-threatening events with large variations in dosing 3. According to a recent national survey, errors associated with the administration of IV prostacyclins include which of the following? a. Use of a programmable IV pump b. Inadvertent pump discontinuance c. Use of specific dosing cassettes d. Availability of dosage calculators 4. Which of the following pharmacy interventions is known to reduce errors associated with high-risk medications? a. Storing high-risk medications in bedside cabinets b. Staffing the hospital pharmacy with additional pharmacists c. Storing look-alike, sound-alike medications in separate locations d. Using tall-man lettering to identify different dosing choices of medications 5. Which of the following may increase operator errors in administration of high-risk medications? a. A higher frequency of interruptions b. More nurses on staff c. Minimizing distractions d. Using checklists during critical points in medication administration 6. Which of the following is the most effective type of educational program that leads to reduction of medication error? a. Computer-based learning b. Class-based lecturing c. Observational learning d. Simulation exercises 7. The use of smart pumps may reduce medication errors as long as which of the following? a. Two nurses double-check the pump programming b. Nurses override the pump in emergency situations c. Nurses do not bypass the medication library d. A pharmacist is assigned to the unit 8. Which of the following agencies contributed to the recommendations in safety strategies for administration of IV prostacyclins? a. Pulmonary Hypertension Professional Network b. National Science Foundation c. Agency for Healthcare Research and Quality d. Alaris Medical Systems Inc 9. Which of the following is a disadvantage in using a patient s home infusion pump rather than a hospital pump? a. The home pump is programmed to infuse in the same units of measure as a hospital pump. b. The home pump infuses in milliliters per hour. c. Nurses are not as familiar with the home pump as with the hospital pump. d. The home pump requires an additional mathematical calculation. 10. What should hospitals consider when deciding whether to store multiple medication cassettes for different patients on an inpatient unit? a. Unit staffing b. Drug half-life c. Patient preference d. Staff skill level with infusion pumps 11. How can patients contribute to reducing errors during administration of IV prostacyclins? a. By assisting in troubleshooting problems with administration b. By storing a backup pump c. By assisting in calculating dosing regimens d. By relinquishing control of their home infusion pumps to hospital staff 12. Recommendations for safety measures in the administration of IV prostacyclins have evolved from which of the following? a. Extensive quantitative research in clinical trials b. Adaptation of study results of other high-risk medications c. Quality improvement studies of generic medication safety d. Qualitative studies of nurse perceptions of staffing Test answers: Mark only one box for your answer to each question. You may photocopy this form. 1. qa 2. qa 3. qa 4. qa 5. qa 6. qa 7. qa 8. qa 9. qa 10. qa 11. qa 12. qa Test ID: C1352 Form expires: October 1, 2016 Contact hours: 1.0 Pharma hours: 0.0 Fee: AACN members, $0; nonmembers, $10 Passing score: 9 correct (75%) Synergy CERP Category A Test writer: Elisa Giglio-Siudzinski, MSN, RN, CCRN For faster processing, take this CNE test online at www.ccnonline.org or mail this entire page to: AACN, 101 Columbia Aliso Viejo, CA 92656. 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Safety Recommendations for Administering Intravenous Prostacyclins in the Hospital Martha S. Kingman and Kelly Chin Crit Care Nurse 2013;33 32-39 10.4037/ccn2013608 2013 American Association of Critical-Care Nurses Published online http://ccn.aacnjournals.org/ Personal use only. For copyright permission information: http://ccn.aacnjournals.org/cgi/external_ref?link_type=permissiondirect Subscription Information http://ccn.aacnjournals.org/subscriptions/ Information for authors http://ccn.aacnjournals.org/misc/ifora.xhtml Submit a manuscript http://www.editorialmanager.com/ccn Email alerts http://ccn.aacnjournals.org/subscriptions/etoc.xhtml Critical Care Nurse is an official peer-reviewed journal of the American Association of Critical-Care Nurses (AACN) published bimonthly by AACN, 101 Columbia, Aliso Viejo, CA 92656. Telephone: (800) 899-1712, (949) 362-2050, ext. 532. Fax: (949) 362-2049. Copyright 2016 by AACN. All rights reserved.