title: Tissue Plasminogen Activator Prescription and Administration Errors within a Regional Stroke System.
abstract: BACKGROUND
  Intravenous (IV) tissue plasminogen activator (tPA) utilization in acute ischemic stroke (AIS) requires weight-based dosing and a standardized infusion rate. In our regional network, we have tried to minimize tPA dosing errors. We describe the frequency and types of tPA administration errors made in our comprehensive stroke center (CSC) and at community hospitals (CHs) prior to transfer.
  
  
  METHODS
  Using our stroke quality database, we extracted clinical and pharmacy information on all patients who received IV tPA from 2010-11 at the CSC or CH prior to transfer. All records were analyzed for the presence of inclusion/exclusion criteria deviations or tPA errors in prescription, reconstitution, dispensing, or administration, and for association with outcomes.
  
  
  RESULTS
  We identified 131 AIS cases treated with IV tPA: 51% female; mean age 68; 32% treated at the CSC, and 68% at CHs (including 26% by telestroke) from 22 CHs. tPA prescription and administration errors were present in 64% of all patients (41% CSC, 75% CH, P < .001), the most common being incorrect dosage for body weight (19% CSC, 55% CH, P < .001). Of the 27 overdoses, there were 3 deaths due to systemic hemorrhage or ICH. Nonetheless, outcomes (parenchymal hematoma, mortality, modified Rankin Scale score) did not differ between CSC and CH patients nor between those with and without errors.
  
  
  CONCLUSIONS
  Despite focus on minimization of tPA administration errors in AIS patients, such errors were very common in our regional stroke system. Although an association between tPA errors and stroke outcomes was not demonstrated, quality assurance mechanisms are still necessary to reduce potentially dangerous, avoidable errors.
authors.affiliation: Department of Neurology, University of Utah, Salt Lake City, Utah.
authors.forename: Lee S
authors.initials: LS
authors.lastname: Chung
authors.affiliation: Department of Neurology, University of Utah, Salt Lake City, Utah.
authors.forename: Aleksander
authors.initials: A
authors.lastname: Tkach
authors.affiliation: Inpatient Pharmacy Services, University of Utah, Salt Lake City, Utah.
authors.forename: Erin M
authors.initials: EM
authors.lastname: Lingenfelter
authors.affiliation: Inpatient Pharmacy Services, University of Utah, Salt Lake City, Utah.
authors.forename: Sarah B
authors.initials: SB
authors.lastname: Dehoney
authors.affiliation: Inpatient Pharmacy Services, University of Utah, Salt Lake City, Utah.
authors.forename: Jeannie
authors.initials: J
authors.lastname: Rollo
authors.affiliation: Department of Neurology, University of Utah, Salt Lake City, Utah.
authors.forename: Adam
authors.initials: A
authors.lastname: de Havenon
authors.affiliation: Department of Neurology, University of Utah, Salt Lake City, Utah.
authors.forename: L Dana
authors.initials: LD
authors.lastname: DeWitt
authors.affiliation: Department of Neurology, University of Utah, Salt Lake City, Utah.
authors.forename: Matthew R
authors.initials: MR
authors.lastname: Grantz
authors.affiliation: Department of Neurology, University of Utah, Salt Lake City, Utah.
authors.forename: Haimei
authors.initials: H
authors.lastname: Wang
authors.affiliation: Department of Neurology, University of Utah, Salt Lake City, Utah.
authors.forename: Jana J
authors.initials: JJ
authors.lastname: Wold
authors.affiliation: Department of Neurology, University of Utah, Salt Lake City, Utah.
authors.forename: Peter M
authors.initials: PM
authors.lastname: Hannon
authors.affiliation: Department of Neurology, Weill Cornell Medical College, New York, New York.
authors.forename: Natalie R
authors.initials: NR
authors.lastname: Weathered
authors.affiliation: Department of Neurology, University of Utah, Salt Lake City, Utah. Electronic address: Jennifer.majersik@hsc.utah.edu.
authors.forename: Jennifer J
authors.initials: JJ
authors.lastname: Majersik
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D011307:Drug Prescriptions / Q000706:statistics & numerical data*; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage*; D005500:Follow-Up Studies; D006764:Hospitals, Community / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D012720:Severity of Illness Index; D020521:Stroke / Q000188:drug therapy*; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage*; D016896:Treatment Outcome
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator
keywords: Errors; stroke; systems of care; tPA; thrombolysis