Prostacyclin Administration Errors in Pulmonary Arterial Hypertension Patients Admitted to Hospitals in the United States: A National Survey

Authors: Martha S. Kingman, M.S.¹; Mark A. Tankersley, Ph.D.²; Sandra Lombardi, R.N.³; Susan Spence, M.S.⁴; Fernando Torres, M.D.¹; Kelly S. Chin, M.D.¹

Presented on November 3, 2009, at the American College of Chest Physicians’ CHEST 2009 conference

Study in Brief:
- This study examined medication errors in inpatient settings and hospital policies for the drug category prostacyclin used to treat pulmonary arterial hypertension (PAH) patients.

- The study was conducted in three phases: First, University Hospital Consortium members were surveyed about prostacyclin infusion policies. Second, nurses at 18 large PAH centers were interviewed about prostacyclin policies and errors. Finally, an online survey was sent to clinicians treating PAH patients, which asked about protocols used to provide medication to PAH patients and adverse drug events, including deaths associated with treatment.

- Overall, 34 percent of the respondents had treated 40 or more PAH patients with intravenous prostacyclins, an indication that many of the respondents were from experienced PAH centers.

- Results of the pharmacy and nursing surveys revealed a lack of standardization of care, including variability on policies regarding use of home versus hospital infusion pumps and how back-up cassettes are stored on nursing units.

- Out of the 97 online survey respondents, 68 percent reported errors, which resulted in 28 serious adverse reactions, including 9 deaths.

¹University of Texas Southwestern Medical Center at Dallas;
²Accredo Health Group, Inc;
³University of California at San Diego;
⁴University of California at San Francisco