A Fatal Outcome After Unintentional Overdosing of Rivastigmine Patches

Lövborg, Henrik; Jönsson, Anna K.; Hägg, Staffan

doi:10.2174/157488612800492717

Cited by 20 publications

(11 citation statements)

References 12 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…14 Adult case reports report significant morbidity and death from rivastigmine exposure. [15][16][17] Our findings of higher rates of reported symptoms and health care facility evaluations with rivastigmine exposures are consistent with the increased morbidity seen in these prior case reports, and merit attention to more exposures from this drug in the years ahead.…”

Section: Discussionsupporting

confidence: 84%

See 1 more Smart Citation

Characteristics of Pediatric Exposures to Antidementia Drugs Reported to a Poison Control System

Thornton

Pchelnikova

Cantrell

2016

The Journal of Pediatrics

View full text Add to dashboard Cite

Section: Discussionsupporting

confidence: 84%

“…There are several prior reports of toxicity from rivastigmine patches in adults but none in pediatric patients. 16,18 Theoretically, these patches could pose a risk similar to those described with transdermal fentanyl or clonidine. 19,20 However, only 3 cases were reported in our study, and none reported any symptoms.…”

Section: Discussionmentioning

confidence: 99%

Characteristics of Pediatric Exposures to Antidementia Drugs Reported to a Poison Control System

Thornton

Pchelnikova

Cantrell

2016

The Journal of Pediatrics

View full text Add to dashboard Cite

“…Sporadic case reports indicate however specific problems related with this drug form, such as incorrect use of multiple patches [3,4], ingestion of used or unused patches [5] and skin reaction [6]. Since potent drugs linked to serious adverse reactions are administered through transdermal patches, medication errors may lead to serious adverse health consequences.…”

Section: Introductionmentioning

confidence: 99%

“…The American Food and Drug Administration (FDA) states that opioids poses the highest risk of harm and death, among approved transdermal patches, because of their risk to cause respiratory depression [7] and has, along with other organizations, issued warnings regarding unsafe use of these patches [8,9]. There are also previous reports of serious and fatal cases due to erroneous administration of multiple patches of rivastigmine, an anticholinergic drug used to treat dementia [4,10]. Prevalence and characteristics of medications errors related to transdermal opioid patches has not been systematically compiled and presented in the scientific literature and such information is needed to develop effective preventive measures.…”

Section: Introductionmentioning

confidence: 99%

Medication errors related to transdermal opioid patches: lessons from a regional incident reporting system

Lövborg

Holmlund

Hägg

2014

BMC Pharmacol Toxicol

View full text Add to dashboard Cite

ObjectiveA few cases of adverse reactions linked to erroneous use of transdermal opioid patches have been reported in the literature. The aim of this study was to describe and characterize medication errors (MEs) associated with use of transdermal fentanyl and buprenorphine.MethodsAll events concerning transdermal opioid patches reported between 2004 and 2011 to a regional incident reporting system and assessed as MEs were scrutinized and characterized. MEs were defined as “a failure in the treatment process that leads to, or has the potential to lead to, harm to the patient”.ResultsIn the study 151 MEs were identified. The three most common error types were wrong administration time 67 (44%), wrong dose 34 (23%), and omission of dose 20 (13%). Of all MEs, 118 (78%) occurred in the administration stage of the medication process. Harm was reported in 26 (17%) of the included cases, of which 2 (1%) were regarded as serious harm (nausea/vomiting and respiratory depression). Pain was the most common adverse reaction reported.ConclusionsOf the reported MEs related to transdermal fentanyl and buprenorphine, most occurred during administration. Improved routines to ascertain correct and timely administration and educational interventions to reduce MEs for these drugs are warranted.

show abstract

“…For instance, problems in correct identification of drug packages are likely to be associated with decreased adherence , as are difficulties in handling drugs during the personalization process (e.g. tablet splitting ), whereas errors in drug dosage and drug application are related to non‐response or toxicity . Hence, the prevention of drug administration errors appears important, particularly in the ambulatory care setting, where the incidence rate might be higher and subsequent strategies to counteract adverse outcomes following administration errors might be less accessible.…”

Section: Discussionmentioning

confidence: 99%

Safeguarding the process of drug administration with an emphasis on electronic support tools

Seidling

Lampert

Lohmann

et al. 2013

Brit J Clinical Pharma

View full text Add to dashboard Cite

AIMSThe aim of this work is to understand the process of drug administration and identify points in the workflow that resulted in interventions by clinical information systems in order to improve patient safety. METHODSTo identify a generic way to structure the drug administration process we performed peer-group discussions and supplemented these discussions with a literature search for studies reporting errors in drug administration and strategies for their prevention. RESULTSWe concluded that the drug administration process might consist of up to 11 sub-steps, which can be grouped into the four sub-processes of preparation, personalization, application and follow-up. Errors in drug handling and administration are diverse and frequent and in many cases not caused by the patient him/herself, but by family members or nurses. Accordingly, different prevention strategies have been set in place with relatively few approaches involving e-health technology. CONCLUSIONSA generic structuring of the administration process and particular error-prone sub-steps may facilitate the allocation of prevention strategies and help to identify research gaps. WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT• Similar to prescription errors also drug administration errors contribute to a large fraction of preventable medication errors and adverse drug events.• Drug administration can be exceedingly complex with regard to dose form, route of administration, number of co-medications, and setting and accordingly, error rates may vary. WHAT THIS STUDY ADDS• The drug-specific drug administration process can be generically structured for distinct dosage forms to allow identification of particularly error prone steps and allocated prevention strategies.• Potential research gaps in error epidemiology and prevention are highlighted. from 2003-2006 [5]). More than 50% of adults administer drugs daily [6]. This fact, however, does not automatically make drug administration a safe and straightforward process and, indeed, drug administration errors are frequent and in the inpatient setting, roughly 30% of errors resulting in adverse drug events (ADE) happen during drug administration [7]. Comparably susceptible to errors is the prescription process [7]. Whereas for the prescribing process electronic prescription platforms with enhanced clinical decision support tools were implemented as promising error prevention strategy [8], similar and theory-driven approaches are only scarcely available for the administration process [9], even though introduction of electronic support in the drug administration process has shown to reduce error rates [10].Drug treatment is a rather complex and demanding task ( Figure 1) and depending on the setting and co-medication a great number of different errors may occur. The aim of this study was to structure the drug administration process (process 5 in Figure 1) in a way that allowed the allocation of current knowledge on frequent sources of errors as well as successful methods to prevent such errors with a particular emphas...

show abstract

A Fatal Outcome After Unintentional Overdosing of Rivastigmine Patches

Cited by 20 publications

References 12 publications

Characteristics of Pediatric Exposures to Antidementia Drugs Reported to a Poison Control System

Characteristics of Pediatric Exposures to Antidementia Drugs Reported to a Poison Control System

Medication errors related to transdermal opioid patches: lessons from a regional incident reporting system

Safeguarding the process of drug administration with an emphasis on electronic support tools

Contact Info

Product

Resources

About