Dosing Errors in Kidney Patients: A Common UK-US Enemy
Lynda A. Szczech, MD: Hello. I'm Dr. Lynda Szczech, president of the National Kidney Foundation in New York, and Associate Professor of Medicine in the division of nephrology at Duke University Medical Center in Durham, North Carolina. It's my pleasure to welcome you to this interview. I'm joined today by Dr. Donal O'Donoghue, National Clinical Director for Kidney Care in England, and consultant renal physician for Safford Royal National Health Service Foundation Trust, in Safford, United Kingdom. Donal, it's so good to be in person with you.
MSCE Donal O'Donoghue, MB, ChB: Yeah, It's great to be here, live at the ASN chatting, fabulous.
Dr. Szczech: Definitely, to tell the people that are listening, we have had a number of these very fun, and, hopefully, educational Skype chats. But this time we are actually in person, which is really neat.
Dr. O'Donoghue: The technology is a bit easier in person.
Dr. Szczech: Now, we discussed and decided that we were going to highlight a recent Medscape article on dosing errors in medications. As we're trying to expand the horizons of primary care physicians and everyone about calculating glomerular filtration rate (GFR) and creatinine clearance, this is the natural next step: to talk about the errors that occur when you don't do it well.
Dr. O'Donoghue: Exactly.
Dr. Szczech: And I know there's been a number of things in the literature that have really pointed to the fact that this is important.
Dr. O'Donoghue: So I think if you look at hospitalized patients, maybe we see 20% of dosing errors, and maybe a quarter of those, 5% overall, are potentially very serious errors.
Dr. Szczech: It's only most common in certain patient types, don't you think?
Dr. O'Donoghue: Well I think probably the multiple comorbid patient with multiple players prescribing, often an elderly patient, and perhaps one that's not as informed about their drugs as they might be (which is putting the blame onto the health system to inform them) and also perhaps with cognitive difficulties. It's quite difficult, the number of medications we're now asking the patients to take. The risk of errors and the risk of another prescriber not knowing the kidney function -- or not knowing the profile of medications the patient is on -- is significant. And, the pharmacists seem to take it very seriously. In the United Kingdom, pharmacists are very diligent. And I have to say, the doctors aren't always as diligent as they should be.
Dr. Szczech: Well this one article[1] that caught both of our eyes, all four of our eyes, noticed that there was a habit in this one particular health care system of rounding up to 1.0 in terms of serum creatinine. That was just a bad, nasty, and lazy habit that could have produced some very serious medical errors. Of course that's milligrams per deciliter.
Dr. O'Donoghue: In the United Kingdom we'd use micromoles. We wouldn't be rounding up creatinine. But people round weights, or people guess at weights. Even when we're not guessing at weights, it's difficult to know how much of that is fluid in some of our patients. We shouldn't treat fluid the same as body weight. It's quite complicated to get it right. If we're prescribing complex medicines, which we are, that have effects, then it behooves us to actually think about what will the concentrations be, and what will the interactions be for that patient.
Dr. Szczech: Most definitely. Now if we think about the pathway of the spark in a nephrologist's mind or a physician's mind in general from "my inpatient needs this medication" to the patient actually receiving it. [then] maybe we should talk about the stakeholders. Who is responsible for what and when? I'm struck by the differences between our two countries, where, we [the US] have more players in the game, because it's not as coordinated a system. We can talk about that also.
So, you write the order. The order gets transcribed. The pharmacist sees it. It has to go through some electronic medical record, and then has to be administered. The stops along the way -- maybe you could inform me about what safeguards you have in place in the United Kingdom to alert physicians that they could be doing it wrong, and then catching it after they do it wrong.
Dr. O'Donoghue: In terms of the chemistry, whenever creatinine is measured in an adult, the physicians and the whole team will get an estimated glomerular filtration rate (eGFR) as well. And so, there should be an alert in the system, but not every hospital has built-in flack alerts to say 'this is CKD3-A," or "there's been a significant change in the creatinine and the GFR." Clearly the eGFR equation is far from perfect in the acute kidney injury situation and in the hospitalized patient. But the increment in the creatinine does tell you something if you bother to look.
We're starting to experiment, I think is perhaps the right word, with more sophisticated electronic alert systems. One of the problems that colleagues have found in primary care is that [there is] alert fatigue, alert overload, and people turn off the alert. We've got to get that balance right. So even before the alert, there's a cultural thing. If we're prescribing, and we are, we are responsible for the consequences of that. That starts at medical school, and needs to be reinforced by our training and our continuing professional development, and by audit to see where the error is happening within our own practices, because they will be occurring there.
So we do have some elements of alerts, and like yourselves, we write the prescriptions, and that would go down to the pharmacy. Sometimes that's still on a paper record, but increasingly that's an electronic transfer. There would be some kind of check within the pharmacy, in terms of whether things are within normal parameters. In some services, there's the ability to check against interactions. And then the medicines would be dispensed and go up to the nurses, and then during the pharmacy rounds. they would give the medicines to the patients. Despite that chain, which is a number of handoffs, and despite the attempt to have some integrity across that pathway, when you actually see what has been prescribed, and when it's been given, and what additionally has been put , it's often eye opening, and occasionally it's tragic.
Dr. Szczech: What you said surprises me a little bit, because I guess I had the preconceived notion that, because it's obviously a coordinated healthcare system, as opposed to the fragmented model in the states with multiple third-party payers and multiple different health systems -- and some being for profit, and some not for profit --that there would be more of a one size fits all procedure and electronic record [in the United Kingdom]. So that surprises me. It occurs to me that the people who are listening to this might want to take a more active role in their hospital system, helping to evaluate electronic medical records, to make sure that these checks are in place, so that they've got the electronic backup for their already stellar judgment.
Dr. O'Donoghue: We found that actually getting the pharmacy into the electronic record and [getting] the remote delivery of information has been one of the most difficult things to get right. That's been a 10-year exercise to do something, which, when describing it, should be fairly obvious to be able to do this, to standardize this. We have this standardize formulary across the country. We have individualized formularies within different health districts. It should be straight forward. And yet, the risk of an electronic error is significant within that system. I think that we've all got iPhone 3s and 4s. I think technology isn't really the issue now. I think it's the commitment to ensure that we use that technology.
Dr. Szczech: Exactly. When the data are there, if you don't use it, you lose something. One last little scientific point that occurred to me when I was listening to you is an interesting literature that's growing about how during acute illness, creatinine production declines. So if you are acutely ill and you're hospitalized, and you're creatinine doesn't go down, then there's been a decline in kidney function. I think that's something that we need to [talk about]. But that's the chapter 2 stuff. I think we should be very happy that we've got the rest of the medical community calculating GFRs, even if they're rounding up.
It has been such a pleasure to do our Skype chat in person. I'm so sorry that the plane ride is so long that we can't do this more often, but maybe next year.
Dr. O'Donoghue: Maybe next year. I'll look forward to it. Thanks very much, Lynda.
Dr. Szczech: Well thank you for joining us. This is Lynda Szczech with Donal O'Donoghue for this interview.