Medication Overdose Research Articles

Relational hopes: A study of the lived experience of hope in some patients hospitalized for intentional self-harm

Hopelessness is a well-established predictor of suicide, and inspiring hope is an important goal in mental health care, but there are few studies of hope among persons with suicidal behavior. The aim of this study was to interpret the lived experience of hope in some patients hospitalized for intentional self-harm. Twelve persons that had engaged in suicidal behavior by ingesting an overdose of medication were interviewed shortly after hospitalization and asked to narrate about their hopes. The transcripts were analyzed using a phenomenological hermeneutic method inspired by Ricoeur's theory of interpretation. The naïve reading was one of hope being relational. The structural analysis identified three themes: hopes for life, hopes for death, and the act of hoping. We interpreted the common theme of the interviews as being definite and indefinite relational hopes for life and death. For clinicians, expressions of indefinite hopes may raise concerns about the low likelihood of fulfillment. However, the expression of indefinite hope may serve to avoid experiencing failure, disappointment, and hopelessness.

Medication Overdoses Leading to Emergency Department Visits Among Children

Medication Overdoses Leading to Emergency Department Visits Among Children

Termination of drug-induced torsades de pointes with overdrive pacing

Drug-induced prolongation of the QT interval is frequently encountered after medication overdose. Such toxicity can result in degeneration to torsades de pointes (TdP) and require overdrive pacing. We present 3 cases in which intentional medication overdose resulted in QTc prolongation with subsequent degeneration to TdP. Despite appropriate care, including magnesium therapy, each case required overdrive pacing for resolution of TdP. Although rarely encountered, patients with drug-induced TdP can be successfully managed with overdrive pacing.

Anesthesia-related Mortality

We have read with great interest both the editorial of Dr. Lagasse1and the article of Li et al. ,2which were related to the epidemiology of anesthesia-related mortality in the United States. The study by Li et al. 2used the data from the National Vital Statistics System and the International Classification of Diseases codes (10th revision) to assess mortality related to anesthesia in the United States between 1999 and 2005. A similar study has been performed in France in 1999 and was correctly referenced by the authors.3The major advantage of such a methodology is the completeness of mortality data retrieved from the National Vital Statistics System. However, when trying to identify deaths related to anesthesia, and to describe the precise degree of imputation, some problems arise.First, the coding system is not detailed enough to capture the precise mechanism(s) that led to death and to ascertain a causal relationship. To assess more precisely the pathophysiological mechanism(s) that led to death, and subsequently to clarify the relation to anesthesia in the sequence of events, an expert analysis remains necessary, which may even be better replaced by a peer discussion with the anesthesiologist in charge of the case and who reported the death.Second, as Dr. Lagasse noticed in his Editorial, the 10th revision of International Classification of Diseases is curiously quite poor regarding anesthesia. Items are more numerous for anesthesia for pregnancy and labor than for anesthesia in general. They explore mainly the surgical time and are mostly limited to anesthetic medication side effects or overdose. What about aspiration occurring during an emergency procedure, for example? Also, what about hemorrhage and/or delayed blood transfusion? This could be one of the limitations of this method, as the authors have noticed themselves in the discussion section of the article. Maybe the use of specific keywords related to anesthesia practice, in addition of the selection of International Classification of Diseases codes as described, could enhance the sensibility of the filter. However, even adding these suggestions might not be powerful enough to capture all cases. In the experience of the Mortality Research Group of the French Society of Anesthesia and Intensive Care,3we have experienced that in some cases death certificates did not mention any specific International Classification of Diseases code or any previously determined specific keyword. The patients' files could be included in the survey only because researchers had chosen to select also death certificates in which a surgical (or invasive) procedure was mentioned.Third, although one could manipulate in many ways the method to select death certificates to detect all cases that have a relation to anesthesia, is it the real problem? The specificity of the filter will never reach 100 percent. We only assess the visible part of the iceberg. Maybe it would be more efficient to monitor the same indicator along time as the trend is likely a valuable marker, even if absolute data are very approximate. It could thus be very interesting to choose an indicator both strongly related to anesthesia and reproducible to assess over time the trend of anesthesia-related mortality through a national mortality database, rather than simply obtain punctual data through a great nationwide survey.*Military Teaching Hospital, Clamart, France. gsmopex@yahoo.fr

Medication safety in acute care in Australia: where are we now? Part 1: a review of the extent and causes of medication problems 2002–2008

BackgroundThis paper presents Part 1 of a two-part literature review examining medication safety in the Australian acute care setting. This review was undertaken for the Australian Commission on Safety and Quality in Health Care to update a previous national report on medication safety conducted in 2002. This first part of the review examines the extent and causes of medication incidents and adverse drug events in acute care.MethodsA literature search was conducted to identify Australian studies, published from 2002 to 2008, on the extent and causes of medication incidents and adverse drug events in acute care.ResultsStudies published since 2002 continue to suggest approximately 2%–3% of Australian hospital admissions are medication-related. Results of incident reporting from hospitals show that incidents associated with medication remain the second most common type of incident after falls. Omission or overdose of medication is the most frequent type of medication incident reported. Studies conducted on prescribing of renally excreted medications suggest that there are high rates of prescribing errors in patients requiring monitoring and medication dose adjustment. Research published since 2002 provides a much stronger Australian research base about the factors contributing to medication errors. Team, task, environmental, individual and patient factors have all been found to contribute to error.ConclusionMedication-related hospital admissions remain a significant problem in the Australian healthcare system. It can be estimated that 190,000 medication-related hospital admissions occur per year in Australia, with estimated costs of $660 million. Medication incidents remain the second most common type of incident reported in Australian hospitals. A number of different systems factors contribute to the occurrence of medication errors in the Australian setting.

Medication Overdoses Leading to Emergency Department Visits Among Children

The high prevalence of medication use increases the potential for medication overdoses, especially among children. This paper describes the burden of unintentional pediatric medication overdoses in order to target new prevention efforts. Data were analyzed in 2007 and 2008 from the National Electronic Injury Surveillance System, collected January 1, 2004, through December 31, 2005, to estimate the number of emergency department visits resulting from unintentional medication overdoses among children aged <or=18 years in the U.S. These data were analyzed by patient demographics, overdose cause, and implicated products, and compared to visits for nonpharmaceutical consumer product poisonings. Based on 3034 cases, an estimated 71,224 emergency department visits for medication overdoses were made annually by children aged <or=18 years, representing 68.9% of emergency department visits for unintentional pediatric poisonings. The rate of unintentional poisonings from medications was twice the rate of those from nonpharmaceutical consumer products (9.2 visits per 10,000 individuals per year [95% CI=7.3, 11.0] vs 4.2 per 10,000 individuals per year [95% CI=3.3, 5.0]). Four fifths (82.2%) of visits for medication overdoses were from unsupervised ingestions (children accessing medications on their own); medication errors and misuse resulted in 14.3% of visits. Most visits (81.3%) involved children aged <or=5 years, and commonly available over-the-counter medications were implicated in one third (33.9%) of visits. Medication overdoses among children, notably unsupervised ingestions, represent a substantial burden in terms of emergency department visits and hospitalizations. New efforts to prevent pediatric medication overdoses are needed.

A series of hospital homicides

Patient deaths in hospitals due to medical staff are very rare. In the autumn of 2006, preliminary proceedings were initiated against a nurse on account of an overdose of medication leading to death, administered during her care of the patient. In the course of these proceedings, exhibits relating to the deaths of a total of 13 patients who had died due to chemical–toxicological causes were reviewed. Nine of them were exhumed. On average, death had occurred 22 months prior to exhumation (range of 1–34 months). The average age of the deceased was 76 years (range of 65–92 years). In five of the cases, analysis results and an evaluation of the medical records confirmed that a final, undocumented dose of sodium nitroprusside or midazolam was administered. After administration of sodium nitroprusside, the active agent rapidly releases nitrogen monoxide, itself undetectable. Another indicator that can be detected, however, is the cyanide that is also released. In one of the exhumed patients, cyanide could still be detected 18 months after death. The nurse stated that her motive was sympathy towards seriously ill patients. She was sentenced res judicata to life imprisonment on five counts of causing the death of a patient.

Implications of using modification of diet in renal disease versus Cockcroft–Gault equations for renal dosing adjustments

The drug-dosing implications of using modification of diet in renal disease (MDRD) versus Cockcroft-Gault equations were analyzed. This retrospective, cohort-controlled study evaluated the implications of using MDRD versus Cockcroft-Gault equations for renal dosing adjustments in patients with stage III-V chronic kidney disease. Dosing simulations were completed for each patient using both MDRD and Cockcroft-Gault methods and then compared to published manufacturer dosing recommendations. Bland-Altman analysis assessed agreement of MDRD and Cockcroft-Gault estimates. Contingency tables were used to evaluate the clinical relevance of dosing adjustments in terms of medication overdoses and underdoses. Data from 4698 patients with stage III-V chronic kidney disease were analyzed. Use of the MDRD equation overestimated the need for dosing adjustments for patients with creatinine clearance (CL(cr)) values of <30 mL/min/1.73 m(2) and underestimated the need for patients with a CL(cr) of >50 mL/min/1.73 m(2). For medication-dosing thresholds, MDRD was associated with an underdose rate of 7.3% and an overdose rate of 9.6% (p < 0.01 for both). For MDRD adjustments within medication-dosing ranges, both overdoses and underdoses occurred in up to 12.4% (p < 0.01). Total dosing errors for MDRD ranged from 9.8% to 18.2%, depending on the medication (p < 0.01). Significant variability exists between the MDRD and Cockcroft-Gault equations for spot dosing adjustments. Use of MDRD estimates with current manufacturer dosing guidelines may result in subtherapeutic medication therapies for patients with stage IV or V disease and supratherapeutic therapies for patients with stage III disease.

National Surveillance of Emergency Department Visits for Outpatient Adverse Drug Events in Children and Adolescents

To describe the national scope and magnitude of outpatient adverse drug events (ADEs) that lead to emergency department (ED) visits in children and adolescents. To conduct an active surveillance of patients 18 years of age or younger who came to EDs with ADEs from Jan 1, 2004, to Dec 31, 2005, through a nationally representative, stratified probability sample of 63 US hospitals with EDs. The main outcome measures were national estimates of the number, type, patient demographics, and clinical characteristics of ADEs. Annually, an estimated 158,520 patients </=18 years old (95% CI, 117,745-199,295; 2 per 1000 persons) were treated in EDs for ADEs. Almost half (49.4%) of these visits occurred in patients between 1 and 4 years of age. Unintentional overdoses were the most common type of ADE (44.9%), followed by allergic reactions (35%), and adverse effects (12.6%). Antimicrobial agents, analgesic medications, and respiratory medications accounted for almost half of ADEs (25.2%, 13.7%, and 10.6%, respectively). Fewer than 1 in 10 patients (9.5%) required hospitalization or extended observation. Interventions targeting unintentional overdoses of medications commonly given to preschool-aged children would likely have the highest impact in reducing ED visits from outpatient ADEs.

Time to End Mind-Brain Split

Time to End Mind-Brain Split

P104

Depression is common among morbidly obese patients according to both epidemiologic studies and the bariatric surgical literature. This comorbidity is not simple, though: symptoms of depression may improve, fail to change, or actually worsen following successful weight-loss surgery (e.g., Ryden et al., 1989; Waters et al., 1991; Dixon et al., 2003). We were prompted to investigate the prevalence of depression and suicidal ideation among our bariatric surgical patients when one was emergently admitted for intentional medication overdose 23 months after laparoscopic adjustable gastric banding (LAGB).

Bowel perforation after single-dose activated charcoal

Patients presenting to the emergency department (ED) after medication overdose are often given activated charcoal initially for gastrointestinal decontamination. Complications of charcoal are rare, but do occur. The following case describes a patient with pre-existing undiagnosed diverticular disease who developed sigmoid perforation after a single dose of activated charcoal, given without cathartic for a drug overdose. A literature search revealed no other cases of bowel perforation associated with single-dose activated charcoal. This case report discusses adverse effects associated with activated charcoal and the role of cathartics in gastrointestinal decontamination.

Suicides in the Young People of Geneva, Switzerland, From 1993 to 2002*

Suicides in Geneva in those less than 25 years old, from 1993 to 2002, were reviewed. Scenes investigations, autopsy findings, toxicology results, and psychiatric history (when available) were examined. There were 65 cases. The average annual suicide rate was 11/100,000. Seventy-seven percent were male, and 23% were female. The youngest was 12 years old and most of the victims were 18 years old and over (89%). For men, the use of firearms was the most common method (38%), followed by fall from height (16%) and drowning (10%). For women, fall from height was the most frequent (40%), followed by firearms and medication overdoses (20% each), hanging (13%), and drowning (7%). Toxicological analysis was performed in 41% of the cases and showed that alcohol was present in 26% and other drugs in 67% of these cases. The most common drugs present were benzodiazepines, cannabis, and cocaine.

Impaired dimensional selection but intact use of reward feedback during visual discrimination learning in Parkinson's disease

It has been suggested that Parkinson's disease (PD) impairs the ability to learn on the basis of reward or reinforcing feedback i.e., by trial-and-error. In many learning tasks, particular ‘dimensions’ of stimulus information are relevant whilst others are irrelevant; therefore, efficient performance depends on identifying the dimensions of these ‘compound’ stimuli and selecting the relevant dimension for further processing. We investigated the ability of patients with PD, as well as patients with Huntington's disease and patients with frontal or temporal lobe lesions, to learn visual discriminations which required either a number of associations to be learned concurrently (the ‘eight-pair’ task) or the selection of information from compound stimuli (the ‘five-dimension’ task), both tasks being learned by trial-and-error. None of the basal ganglia disorder patient groups was impaired on the eight-pair task, militating against a crucial role for these brain structures in trial-and-error learning per se. Patients with mild, medicated PD, but not unmedicated PD patients, were impaired at identifying all five feature dimensions in the five-dimension task, implying dopaminergic ‘overdosing’ of the ability to analyse compound stimuli in terms of their component dimensions. Temporal lobe lesion patients performed similarly, suggesting that the temporal lobe may be the site of the medication overdose effect. Patients with severe, medicated PD were impaired at compound discrimination learning on the five-dimension task in the absence of an underlying impairment in identifying component stimulus dimensions; this pattern resembled that seen in Huntington's disease and frontal lobe lesion patients, implying that fronto-striatal circuitry is involved in the formation of rules based upon selected stimulus dimensions.

California Hospital System Admits to Errors in Multiple Medication Overdose Deaths

California Hospital System Admits to Errors in Multiple Medication Overdose Deaths

California Hospital System Admits to Errors in Multiple Medication Overdose Deaths

California Hospital System Admits to Errors in Multiple Medication Overdose Deaths

Serious Suicide Attempts in a State Corrrectional System and Strategies to Prevent Suicide

The characteristics of offenders who attempt suicide in prisons indicate that they are mostly white males, likely to be property offenders, serving less than ten years, suffer from depression and personality disorders, experience significant psychosocial stressors, often have a cellmate and use predominantly cutting and slashing. A significant percentage use lethal methods such as attempted hanging and overdose. Those who use lethal methods tend to be genuine in their intent and have many features common to those who commit suicide. Comparison of those who used lethal methods with a cohort of inmates who committed suicide indicated no significant differences in gender, race, age, crime type, diagnosis, and prior or current psychiatric care. However, the suicide completers tended to have more psychiatric symptoms such as delusions, hallucinations, impulsivity and guilt feelings, as well as experience of conflicts, ridicule and/or rape immediately preceding the self harm acts. Furthermore, more completers experienced new convictions, medical conditions, psychosocial stressors, and had shown prior suicidal behaviors. They were likely to be held in maximum security prisons and in single cells. While hanging dominated the completed suicides, medication overdose was more common among the lethal attempters. The authors discuss multiple strategies to deal with the identified group of suicide attempters in order to prevent subsequent serious attempts or suicides. They include comprehensive mental health (MH) services delivery, implementation of a suicide prevention policy, timely inpatient and involuntary treatment, watch take procedure for psychotropic medications, noncompliance management, suicide watch, therapy, use of liquid medications, elimination of Benzodiazepines and timely action by MH, correctional and medical staff.

Patient Rep Reverses Position On SSRI Black-Box Warning

Patient Rep Reverses Position On SSRI Black-Box Warning

Toxicology and overdose of atypical antipsychotic medications in children: does newer necessarily mean safer?

Atypical antipsychotic medications (second-generation antipsychotics) have been increasingly used in the treatment of a number of psychotic disorders since their introduction in 1988, with the newest medication introduced in 2002. Justification for their use includes claims of equal or improved antipsychotic activity over first-generation antipsychotics, increased tolerability, and decreased side effects. However, there are still significant adverse effects and toxicities with this class of medications. Toxicologic exposures and fatalities associated with atypical antipsychotics continue to increase in the United States, with 32,422 exposures and 72 deaths in 2003. There have also been Food and Drug Administration warnings in the past year about how some atypical antipsychotics have been marketed to minimize the potentially fatal risks and claiming superior safety to other atypical antipsychotics without adequate substantiation, indicating the toxicologic potential of these agents may be underestimated. Continued research to evaluate adverse effects and tolerability of atypical antipsychotics compared with first-generation antipsychotics and each other is reviewed. This article also reviews the pharmacodynamics, pharmacokinetics, and drug interactions with these medications. New therapeutic monitoring recommendations for this class of medications have also been proposed. Finally, clinical toxicity in overdose and management are reviewed. While new atypical antipsychotic medications may have a safer therapeutic and overdose profile than first-generation antipsychotic medications, many adverse and toxic effects still need to be considered in therapeutic monitoring and overdose management.

Injuries and Unintentional Medication Overdoses

Injuries and Unintentional Medication Overdoses