Medication Error, Diabetes And Pharmacokinetics: An Overview

Type 1 and Type 2 Diabetes

Discuss about the Medication Error, Diabetes and Pharmacokinetics.

The type of medication error that occurred in the case study is the wrong route for drug administration. The medication wrong route administration of crushed up ciprofloxacin into the nasogastric tube (NGT) led to the death of Mrs. C.  After the nurse RN.R administered the crushed ciprofloxacin via the PICC line, the patient became cyanosed, hypoxemic and unresponsive eventually leading to death of the patient. The drug administration via wrong route is a serious medication error that leads to adverse effects and complications in the patient (Mondal et al., 2016). She also had a risk for aspiration and sub-optimal oral nutrition as advised by the healthcare professionals and despite of that, she was inserted with a nasogastric tube (NGT). The nurse drew the paste into a standard size and injected the through a non-luer lock syringe into the NGT. She was advised by the supervised nurse RN.C to administer the drug through the luer lock syringe; however, she injected the medication through the NGT. The drug administration through NGT requires a large nozzle; however, the drug was administered through a non-luer lock syringe breaking it into a crush and paste.

Moreover, the nursing staff looking after Mr. C did not give her evening medicines including the oral ciprofloxacin and intravenous frusemide despite of knowing that she had risk for suboptimal oral nutrition. After this incident, when Mrs. C had an episode of low oxygen saturation levels, NGT was re-inserted. After the insertion of PICC line, RN.C was advised by the nurse-in-charge (NIC) to administer the medications via the PICC in a luer lock syringe. After this, the nurse, RN.R returned to the drug room and then transferred the crush ciprofloxacin into a luer lock syringe and then injected to the PICC line. After this administration, the patient became cyanosed, hypoxic and pronounced deceased soon after.  The nurse should have taken proper precautions before the drug administration that might have prevented the medication error that took place due to the use of non-luer lock syringe that might have resulted in the lodging of an embolus or foreign material in the vessels of the brain, heart and lungs.

There was a requirement of safety measures that should have been taken during the drug administration as it would have avoided the medication wrong route administration. The nurse should have been careful regarding the route for the administration of the drug, ciprofloxacin. She should have been assisted by a supervisor nurse who would have been able to assist her while the drug administration. She should have been informed prior to the administration of the drug through a NGT that the medication should be drawn by a larger nozzle and not by a non-luer lock syringe (Lehne & Rosenthal, 2014). Even though she was informed by the supervisor nurse to draw blood and administer medication through the PICC line, the nurse RN. R intended to administer the drug via NGT. Another safety measure that would have been taken was the drawing of blood and drug administration through PICC line should have assisted by an experienced nurse, instead of RN.C who had no prior experience working with PICC lines.

Administration of Humulin R

The nurse, RN.R was previously instructed by the NIC to administer ciprofloxacin via a NGT by crushing it, instead of giving it orally. Later, she was advised to administer the drug via PICC line, though she intended to administer the drug via NGT. The use of luer lock syringe is beneficial than the non-luer syringe as it provides a secure connection and prevents the accidental removal of the needle. At the time of injection of the fluids, it reduces the chances of leakage by providing a permanent seal (Raban & Westbrook, 2014). Moreover, the drug administration via NGT requires a larger nozzle and this shows that precautions should have been taken during the procedure.

The pathophysiology of type 1 diabetes (T1DM) is autoimmunity in which there is production of antibodies against a certain viral protein that triggers the autoimmune response against the beta cells in Islets of Langerhans in pancreas. The mass of beta cells decrease in number along with decrease in insulin secretion that result in inadequate insulin production required for the maintenance of blood glucose levels at normal level. The hyperglycemia develops and T1DM is diagnosed being more common in juveniles (Atkinson, Eisenbarth & Michels, 2014).

In type 2 diabetes (T2DM) two conditions occur where either the body is unable to produce adequate amounts of insulin that is required to meet the body needs or there is development of insulin resistance. There is development of insulin resistance where the cells of the body like liver, fat cells and muscles fail to respond to the insulin leading to overall increase in glucose levels in blood.  It is more common in middle age groups like late 30s or early 40s (Zaccardi et al., 2016).

Brown is diagnosed with T1DM as he manifests the symptoms of TIDM. In T1DM, the blood glucose levels increase quickly as there is no insulin to control the glucose levels (Ashoor et al., 2016). The distinguishing feature of T1DM from T2DM is that a person is not obese. In the case study, Mr. Brown has lost around 10 kgs over the past weeks and on admission was diagnosed with new-onset diabetes. The patient also manifested symptoms like extreme thirst-dehydration, frequent urination and nausea or vomiting that comply with the symptoms of T1DM. The onset of T1DM is during the juvenile period among the children and adolescents and the patient in the case scenario is 16 year old where the weight loss is the most common symptom before the diagnosis of T1DM (Russell et al., 2014).

Considerations during Humulin R Administration

The patient in case scenario is prescribed Humulin R for stabilizing his condition of high blood glucose levels. Insulin treatment is given as it replaces or supplements the body’s natural insulin that helps to restore the normal blood-glucose levels.

The mechanism of action of humulin R is same as the natural insulin that is present in the body. The humulin R binds to the insulin receptors on the body cells like muscle, fat tissue or liver to increase the uptake of glucose from the bloodstream. Humulin R also decreases the production of glucose by the liver and has immediate acting insulin (Sandow et al., 2015). It starts working within 1 to 2 hours after its injection into the skin and effective up to 16 to 24 hours. Humulin R is isophane insulin that is combined with short acting insulin given before the meals so that it controls the glucose level that occurs after eating meals.

During the Humulin R administration, a nurse should be careful that the injection should not enter any blood vessel while injecting the humulin R into the skin of the thighs, upper arm, and abdomen. The most important consideration is to measure the blood glucose levels of the patient before the administration as the dose is dependent on the blood glucose level at the time of administration (Bridgeman & Dalal, 2015). Another consideration is that the nurse should change the site of injection administration so that there is no pitting or skin thickening. This occurs when the injection is administered at one site repeatedly. The nurse should also keep into consideration the side effects of the insulin therapy that might occur due to hypoglycaemia. The symptoms include tremor, cold sweats, anxious feeling, weakness, tiredness or nausea that needs to be taken care of during the insulin therapy. The insulin should also not be injected into a vein.

Pharmacokinetics (PK) is a branch of pharmacology that involves the determination of the fate of the substances that are administered inside the living body. It also encompasses the analysis of chemical metabolism and the fate of the substance from the time it is administered inside the body (Trescot, 2016). It helps to know the way body affect a specific chemical or xenobiotic substance after it is administered inside the body through the mechanism of liberation, absorption, distribution, metabolism and excretion.  These aspects are important to know for the safe administration of medications to the patients. The pattern of absorption, distribution, metabolism and excretion differs according to age and the PK of drugs is altered by age. These mechanisms greatly differ in elders as compared to adults.

Pharmacokinetics

The advancing age has implications on the mechanism of PK as there is impairment of functions in the regulatory processes that helps to provide the functional integration between the organs and cells. The ageing process reduces the gastrointestinal motility and blood flow with reduces gastric secretion. This results in elevation of pH and this causes reduction in drug absorption. These absorptive changes that are age-related greatly alter the absorption and its onset of action. When compared to young adults, there is proper functioning of the regulatory processes with proper pH and gastric secretion that leads to better absorption of drugs (Reeve, Wiese & Mangoni, 2015).

Distribution in elders are greatly altered as the muscle mass is declines and there is increase in body fat will lead to the greater distribution of the drugs that are fat soluble. Moreover, the volume of distribution is reduced for the drugs in muscle tissue. Eventually, the half-life and loading dose is reduced. The muscle mass in young people is well distributed and so there is proper distribution of drugs in body fat and muscle tissue (Hubbard, O’Mahony & Woodhouse, 2013).

Metabolism is also altered in old people as the hepatic blood flow is reduced and the drug is introduced to the liver at a slow rate. The intrinsic metabolic activity and liver mass is also reduced during ageing. Due to reduction in metabolic activity and hepatic blood flow, metabolism is altered. There is normal metabolism in young adults due to proper intrinsic metabolic activity and there is proper conversion of drug into a more water soluble compound by increasing the polarity (Davies & O’mahony, 2015).

Excretion of drugs is altered as there is decline in renal function with reduction in blood flow to kidneys, decrease in kidney mass and size and functioning of the nephrons. The excretion of drugs in young adults takes place normally as there is proper glomerular filtration and active tubular secretion (Wallace & Paauw, 2015).

The nursing interventions are required while administering the medications to the older people and young adults. The nurse should take into account the right dose, type of medication and most importantly, the right route of administration as they have to confirm that the medication given through a particular route can be taken or received by the patient. Another nursing intervention is to take into account the physical assessment of the patient like vital organs, sensory and cognitive barriers and most importantly, age of the patient. The pharmacokinetics greatly depends on the age of the patient (Cheragi et al., 2014).

References

Ashoor, M. F., Bintouq, A. K., Rutter, M. K., & Malik, R. A. (2016). Pancreatic islet cell transplantation as a treatment for brittle type 1 diabetes: A case report and review of the literature. Journal of Taibah University Medical Sciences, 11(4), 395-400.

Atkinson, M. A., Eisenbarth, G. S., & Michels, A. W. (2014). Type 1 diabetes. The Lancet, 383(9911), 69-82.

Bridgeman, M. B., & Dalal, K. S. (2015). Insulin preparations. Nursing2016, 45(7), 68.

Cheragi, M. A., Manoocheri, H., Mohammadnejad, E., & Ehsani, S. R. (2014). Types and causes of medication errors from nurse’s viewpoint. Iranian journal of nursing and midwifery research, 18(3).

Davies, E. A., & O’mahony, M. S. (2015). Adverse drug reactions in special populations–the elderly. British journal of clinical pharmacology, 80(4), 796-807.

Hubbard, R. E., O’Mahony, M. S., & Woodhouse, K. W. (2013). Medication prescribing in frail older people. European journal of clinical pharmacology, 69(3), 319-326.

Lehne, R. A., & Rosenthal, L. (2014). Pharmacology for nursing care. Elsevier Health Sciences.

Mondal, M. K., Roy, B. R., Banik, S., & Banik, D. (2016). Medication Error in Anaesthesia–A Review. Journal of the Bangladesh Society of Anaesthesiologists, 27(1), 31-35.

Raban, M. Z., & Westbrook, J. I. (2014). Are interventions to reduce interruptions and errors during medication administration effective?: a systematic review. BMJ quality & safety, 23(5), 414-421.

Reeve, E., Wiese, M. D., & Mangoni, A. A. (2015). Alterations in drug disposition in older adults. Expert opinion on drug metabolism & toxicology, 11(4), 491-508.

Russell, S. J., El-Khatib, F. H., Sinha, M., Magyar, K. L., McKeon, K., Goergen, L. G., … & Damiano, E. R. (2014). Outpatient glycemic control with a bionic pancreas in type 1 diabetes. New England Journal of Medicine, 371(4), 313-325.

Sandow, J., Landgraf, W., Becker, R., & Seipke, G. (2015). Equivalent recombinant human insulin preparations and their place in therapy. Eur Endocrinol, 11(1), 10-6.

Trescot, A. M. (2016). Opioid Pharmacology and Pharmacokinetics. In Controlled Substance Management in Chronic Pain (pp. 45-62). Springer International Publishing.

Wallace, J., & Paauw, D. S. (2015). Appropriate prescribing and important drug interactions in older adults. Medical Clinics of North America, 99(2), 295-310.

Zaccardi, F., Webb, D. R., Yates, T., & Davies, M. J. (2016). Pathophysiology of type 1 and type 2 diabetes mellitus: a 90-year perspective. Postgraduate medical journal, 92(1084), 63-69.