Reducing medication errors: potential benefits of bolus thrombolytic agents

A recent Institute of Medicine report highlighted the high incidence of medical errors in clinical practice, and the important fact that errors are associated with increased mortality. The administration of thrombolytic therapy for acute myocardial infarction is a particularly high-risk situation for emergency physicians. The combination of extreme time pressure with a narrow "therapeutic window" increases the potential for adverse outcomes due to dosing errors. Numerous trials have found that the dose of thrombolytic therapy is closely related to outcomes, with too low a dose associated with lower rates of infarct-related artery patency and higher doses associated with increased bleeding and intracranial hemorrhage. In the GUSTO-I trial, 13.5% of patients treated with streptokinase and 11.5% of patients treated with tissue plasminogen activator (t-PA) had a medication error (i.e., incorrect dose or infusion length). Most importantly, 30-day mortality was significantly higher in patients with medication errors: for t-PA dosing errors mortality was 7.7% vs 5.5% for patients who received the correct t-PA dose (p < 0.001), with similar findings for streptokinase. More recent data from the InTIME2 trial and other studies showed that use of a bolus thrombolytic agent reduced the rate of medication errors. Thus, use of the simpler bolus thrombolytic agents may reduce emergency department medication errors, and thus improve overall clinical outcome.