R E V I E W S & A N A LY S E S Events Associated with the Prescribing, Dispensing, and Administering of Medication Loading Doses Stacy L. Carson, PharmD, BCPS, FISMP INTRODUCTION Patient Safety Analyst A loading dose is an initial large dose of medication administered to rapidly achieve Michael J. Gaunt, PharmD therapeutic levels in the body.1,2,3 The clinical and therapeutic need for administration Senior Patient Safety Analyst of a loading dose can vary based on the patient’s condition and the medication. For Pennsylvania Patient Safety Authority example, a therapeutic level of phenytoin may be needed quickly to stabilize a patient after a seizure.4 Other medications commonly administered with loading and mainte- nance doses include the antidote acetylcysteine, the cardiovascular agent digoxin, and ABSTRACT the anticonvulsant fosphenytoin. Loading doses are typically followed by maintenance doses, which are given in lower doses to maintain therapeutic levels on a medium- to A loading dose is an initial dose of med- long-term basis. The combination of loading doses and maintenance doses creates com- ication administered to rapidly achieve plexity in prescribing, dispensing, and administering medications. This combination therapeutic levels. The determination can lead to medication errors stemming from all nodes in the medication-use process. of a loading dose can be complicated, involving calculations dependent upon There is scarce literature that addresses the problems and errors associated with loading patient characteristics. This, combined dose regimens. A study by Hayes et al. demonstrated the complexity of acetylcysteine with the need to also administer main- dosing regimens (which includes loading and maintenance doses) for the treatment of tenance doses, creates complexity and acetaminophen overdoses.5 This retrospective chart review of a regional poison control opportunities for errors. From June center’s records found a 33% error rate, which included medication errors in all phases 2004 through May 2012, Pennsylvania of the medication-use process. The types of errors found included incorrect dose, incor- facilities reported to the Pennsylvania rect infusion rate, and more than one hour of interruption in therapy. A case report by Patient Safety Authority 580 events Cottington et al. described a fatality from a gross overdose administered for a loading associated with the prescribing, dispens- dose test of methionine.6 Another study by Oudin et al. found prescribing problems ing, and administering of medication with vancomycin loading doses.7 Of the 13 prescription errors the authors found, loading doses, 15 of which were harm- seven involved vancomycin loading doses, including five cases in which the loading ful events. The most common types of dose was not prescribed, one case of a prescription delay, and one case of higher-than- events reported included “loading dose intended dosing. omitted or delayed,” “wrong loading In November 2010, the National Patient Safety Agency (NPSA) in the United Kingdom dose given,” and “loading dose given published an alert regarding fatalities associated with loading dose errors and strategies multiple times.” The predominant medi- to prevent their occurrence.2,3 From January 2005 through April 2010, the NPSA’s cation associated with these reports was National Reporting and Learning System received 1,165 reports related to loading vancomycin (14.8%, n = 86). Phenytoin doses, including 2 fatalities (both involving phenytoin), 4 cases of severe harm, and was the medication most frequently 102 cases of moderate harm. The cases that resulted in severe patient harm or death involved in harmful events (26.7%, n = 4). involved incorrect loading doses, omitted or delayed loading doses, or unintentional Strategies to prevent errors associated continuation of loading doses.2 with loading doses include developing standardized clinical guidelines on how Analyses of events involving loading doses of medications reported by Pennsylvania to prescribe, administer, and monitor healthcare facilities to the Pennsylvania Patient Safety Authority have identified the loading and maintenance doses; stan- most common types of events and medications associated with the prescribing, dispens- dardizing electronic and paper order sets ing, and administering of medication loading doses in Pennsylvania. and protocols; and including a thorough review of current drug therapy during METHODOLOGY patient handoffs. (Pa Patient Saf Advis The term “loading” was used to query all event types in the Pennsylvania Patient Safety 2012 Sep;9[3]:82-8.) Reporting System (PA-PSRS) database reported from June 2004 through May 2012. The initial query yielded 905 reports. After eliminating reports that were not applica- ble (e.g., “patient bumped forehead while loading on wheelchair lift in van,” “continue offloading pressure on the heel”), 580 reports were analyzed in detail to identify trends and contributing factors. Page 82 Pennsylvania Patient Safety Advisory Vol. 9, No. 3—September 2012 ©2012 Pennsylvania Patient Safety Authority AGGREGATE ANALYSIS Table 1. Top 20 Medications Involved in Events Associated with the Prescribing, Dispensing, and From events reported from June 2004 Administering of Medication Loading Doses from June 2004 through May 2012 (n = 452) through May 2012, analysts identified NO. OF % OF TOTAL EVENTS 580 events involving breakdowns in the MEDICATION NAME EVENTS (N = 580) prescribing, dispensing, and administra- Vancomycin 86 14.8 tion of medication loading doses. A Clopidogrel 54 9.3 breakdown of these events by harm score, Phenytoin 50 8.6 which is adapted from the National Coor- HYDROmorphone* 26 4.5 dinating Council for Medication Error Morphine* 23 4.0 Reporting and Prevention’s harm index,8 Acetylcysteine 22 3.8 shows that nearly 79% (n = 458) of the Digoxin* 22 3.8 events reached the patient (harm score = Fosphenytoin 22 3.8 C to I). Overall, 97.4% (n = 565) of the events were reported as Incidents (harm Azithromycin 19 3.3 score = A to D) and 2.6% (n = 15) as Seri- Gentamicin 18 3.1 ous Events (harm score = E to I), includ- Tigecycline 16 2.8 ing two events resulting in death. Caspofungin 16 2.8 In total, there were over 70 medications Caffeine citrate 14 2.4 associated with loading doses involved in Amiodarone* 11 1.9 events reported to the Authority. Table PrednisoLONE 10 1.7 1 lists the top 20 medications involved Heparin* 10 1.7 in events related to loading dose issues. Magnesium sulfate* 9 1.6 The antibiotic vancomycin was the most PHENobarbital 8 1.4 frequently reported medication (14.8%, n Fluconazole 8 1.4 = 86); six anti-infective agents were in the MethylPREDNISolone 8 1.4 top 20. In contrast, the United Kingdom’s * A high-alert medication NPSA incidents related to loading doses in its November 2010 Rapid Response Report identified warfarin as the most frequently reported medication involved.3 While 10 medications (i.e., amiodarone, Table 2. Medications Involved in Harmful Events Associated with the Prescribing, Dispens- caffeine citrate, clopidogrel, digoxin, ing, and Administering of Medication Loading Doses from June 2004 through May 2012 gentamicin, heparin, magnesium sulfate, MEDICATION HARM HARM HARM NO. OF morphine, phenytoin, vancomycin) NAME SCORE I† SCORE F‡ SCORE E§ EVENTS appear in the top 20 medications involved Phenytoin 1 1 2 4 in events associated with loading doses in Morphine* 3 3 both Pennsylvania and the United King- Digoxin* 1 1 2 dom, only phenytoin appears in the top HYDROmorphone* 2 2 five medications for both. Other drugs Aminocaproic acid 1 1 in the top five in the United Kingdom include amiodarone and digoxin. PHENobarbital 1 1 ClonazePAM 1 1 Six high-alert medications, drugs that bear a heightened risk of causing signifi- LevETIRAcetam 1 1 cant patient harm when used in error,9,10 Total Reports of Harm 15 appear in the top 20. Of the reported * A high-alert medication harmful events, the high-alert medications † An event occurred that contributed to or resulted in death. ‡ An event occurred that contributed to or resulted in temporary harm and required initial or prolonged morphine, digoxin, and HYDROmor- hospitalization. phone were involved in roughly half § An event occurred that contributed to or resulted in temporary harm and required treatment or (n = 7) of these events (see Table 2). intervention. Vol. 9, No. 3—September 2012 Pennsylvania Patient Safety Advisory Page 83 ©2012 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S Table 3. Top Event Types Associated with Prescribing, Dispensing, and Administering Medication Loading Doses from June 2004 through May 2012 (n = 357) % OF TOTAL REPORTS EVENT TYPE EVENT SUBTYPE NO. OF EVENTS (N = 580) Loading dose error Loading dose omitted or delayed 148 25.5 Wrong loading dose given 88 15.2 Loading dose given multiple times 41 7.1 Maintenance dose error Maintenance dose missed 37 6.4 Maintenance dose given at wrong time 23 4.0 Wrong maintenance dose given 20 3.4 Note: Based on information contained within the reports and event descriptions, Authority analysts categorized reports into two event types and related event subtypes. Authority analysts first categorized the In Pennsylvania, five medications, namely administered to her patient. Protocol types of events into two groups—those vancomycin (24.3%, n = 36), clopidogrel was then adjusted appropriately. involving an error with the loading dose (12.2%, n = 18), phenytoin (11.5%, n = 17), and those involving an error with the morphine (5.4%, n = 8), and gentamicin Wrong Loading Dose maintenance dose. Analysts then further (5.4%, n = 8) were involved in nearly 60% Analysts identified wrong loading dose categorized the reports into subtypes of (n = 87) of omitted or delayed loading events as the second most frequently these two general classifications. Table 3 dose events. reported (15.2%, n = 88) events associ- lists the top event types. It should be Transfer within and between facilities ated with the use of loading doses. This noted that not enough information was introduces vulnerability to the system,11 should not come as a surprise, as the provided to determine what occurred in making it easier for an error to occur and determination of a loading dose can roughly 20% (n = 117) of reports. reach the patient. Breakdowns or inter- be complicated, involving calculations ruptions when patients were transferred dependent upon patient characteristics FOCUSED EVENT ANALYSIS between units within a hospital or between such as weight or organ function and/ hospitals was a leading contributor or laboratory results. Comparatively, Loading Dose Omitted or (16.2%, n = 24) to omitted loading doses. the NPSA found that the prescribing or Delayed Often, this involved situations in which administration of an incorrect loading The goal of administering a loading dose a loading dose was ordered in the emer- dose was the most frequent (41%) event of certain medications is to reach thera- gency department (ED), but the patient type related to loading dose issues.3 peutic drug concentrations or levels within was transferred prior to receiving the dose, Once again, vancomycin was the drug most the body as soon as possible. An omitted as the following examples illustrate: frequently involved (17%, n = 15) in these or missed loading dose may contribute Orders written at 2200 in ED for events. Other medications involved in to therapeutic failure and deterioration IV [intravenous] Dilantin® loading wrong loading dose events included clopi- of the patient. Analysts identified “load- dose. Patient presented to floor at dogrel (10.2%, n = 9), HYDROmorphone ing dose omitted or delayed” as the most approximately 0200. The Dilantin (8%, n = 7), morphine (4.5%, n = 4), and frequently reported (25.5%, n = 148) type [loading dose] was not administered acetylcysteine (4.5%, n = 4). of event associated with the use of medi- in ED. Patient admitted with diagno- In 31.8% (n = 28) of wrong loading dose cations requiring loading doses. This is sis of new onset seizures. events, a maintenance dose was ordered comparable to what the NPSA noted in its Patient prescribed vancomycin proto- or administered as the loading dose. November 2010 Rapid Response Report.3 col in ED. Loading dose for protocol As a result, a lower dose than clinically In that report, the NPSA found that omis- sent to ED at approximately 9:30 indicated was administered. While many sion or delayed administration of a load- to be administered at 10:00. Phar- of the event reports do not describe why ing dose occurred in 24% of incidents that macist spoke to nurse on unit about this dose mix-up occurred, a number do were related to loading dose issues. This another patient when she learned indicate that the wrong dose was selected represented the second most frequently that [the] loading dose was not on the unit when pharmacy delivered the reported event in the NPSA data set. loading dose and maintenance dose(s) Page 84 Pennsylvania Patient Safety Advisory Vol. 9, No. 3—September 2012 ©2012 Pennsylvania Patient Safety Authority at the same time. For example, see the care unit] and, in the ICU, continued based on a review of events reported to following: to have seizure activity. The physician the Authority, observations from the Insti- Physician ordered tigecycline 100 mg in the ICU ordered a loading dose of tute for Safe Medication Practices, and IVPB [IV piggyback] stat followed by fosphenytoin. After the medication recommendations in the literature. an order for tigecycline 50 mg IVPB was administered, it was discovered — Review organizational processes every 12 hours. According to the that the patient had already received associated with medications requir- pharmacy, the doses were dispensed, a loading dose in the ED. The ing loading doses in order to but the RN [registered nurse] admin- patient received a total of 2,400 mg identify risks. istered tigecycline 50 mg IVPB as the of fosphenytoin instead of 1,200 mg. — Restrict and limit the physical avail- initial stat loading dose instead of the Per the physician, it was reported to ability of medications requiring 100 mg bag. him that the patient only received loading doses, as appropriate.3 “benzos” in ED. However, alerts did fire in the computer system for “dupli- — Develop standardized clinical Loading Dose Given Multiple guidelines on how to prescribe, cate therapy,” and the first dose was Times documented in the EMAR [electronic administer, and monitor loading and A third subtype of loading dose error medication administration record]. maintenance doses.3 is “loading dose given multiple times.” — Standardize electronic and paper Authority analysts identified this subtype Patient was admitted through the order sets and protocols. Ensure that as the third most frequently reported ED. Report was taken by charge these order sets are well designed. (7.1%, n = 41) loading dose event. The nurse. The nurse in the ED did Well-designed order sets have the NPSA also noted that a loading dose was notify charge nurse that the patient potential to repeated in error in 7% of loading dose had been given 1 mg loading dose of Dilaudid® prior to coming to the coordinate care by commu- incidents in the United Kingdom.3 These nicating best practices across events can result in supratherapeutic drug floor. Patient arrived to the floor, and there was a delay in patient getting disciplines and lines of service, concentrations or levels within the body put in the system by admissions. . . . reduce variation and accidental leading to adverse events. In Pennsylvania, Loading dose was administered a oversight through standardized 7.3% (n = 3) of these events resulted in second time, as it was not marked off formatting and presentation, harm, accounting for 20% of all harmful events associated with the prescribing, on floor orders. After being started on enhance workflow with instruc- dispensing, and administering of medica- PCA [patient-controlled analgesia], tions that are easily understood tion loading doses. patient was found to have low O2 and intuitively organized, and [oxygen] saturations and had to be reduce the risk for medication Clopidogrel was the drug most frequently placed 6 L NC [nasal cannula]. errors through integrated safety involved (24.4%, n = 10) in these events. However, in 48.8% (n = 20) of “loading alerts and reminders.12,13 Other drugs involved in “loading dose given multiple times” events include dose given multiple times” events, — Establish guidelines for communica- digoxin (9.8%, n = 4), phenytoin (7.3%, insufficient information was provided to tion during patient transfers. Items n = 3), and fosphenytoin (7.3%, n = 3). determine what contributed to the event. to consider for inclusion are a brief overview of the patient’s Similar to “loading dose omitted or RISK REDUCTION STRATEGIES status, delayed” events, vulnerabilities introduced during the patient transfer process was Healthcare facilities can strive to identify essential patient information, the leading contributor (19.5%, n = 8) to systems-based causes of the errors associ- physician orders that will be events involving multiple administrations ated with the prescribing, dispensing, implemented pre-transport (e.g., of a loading dose. For example, see the and administering of medication loading loading dose, sedation, pain following: doses and implement effective risk reduc- management), tion strategies to prevent harm to patients. physician orders that will need Patient was admitted through the ED Although many of the reports submitted with seizures. In the ED, the patient to be implemented post- to the Authority did not explicitly reveal transport, and was loaded with fosphenytoin along all of the causes and contributing factors, with benzodiazepines. The patient confirmation of patient arrival healthcare facilities may consider the strat- was admitted to the ICU [intensive time.11 egies described in this section, which are Vol. 9, No. 3—September 2012 Pennsylvania Patient Safety Advisory Page 85 ©2012 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S — Provide clear documentation to patient care unit and confused for dispensing, and administering of medica- ensure that all applicable patient one another. tion loading doses were reported to the information is available and commu- — Consider differentiating the packag- Authority from June 2004 through May nicated to the next level of care.14 ing and labeling of loading doses and 2012. The predominant types of events — Include a thorough review of cur- maintenance doses to reduce the risk identified through analysis of event rent drug therapy during handoffs that they may be confused for one descriptions are “loading dose omitted in care. Such reports, particularly at another. or delayed,” “wrong loading dose given,” a change of shift, can help with the “loading dose given multiple times,” timely discovery of instances when CONCLUSION “maintenance dose missed,” “mainte- prescribed medications have been nance dose given at wrong time,” and Loading doses are administered to rapidly omitted by accident.15 “wrong maintenance dose given.” There achieve therapeutic levels in the body and Explore having pharmacy dispense are similarities in the types of events, — are typically followed by maintenance loading and maintenance doses frequency of the events, and medications doses to maintain therapeutic levels on a separately, closer to the time when involved in the events seen in Pennsylva- medium- to long-term basis. The combina- each one is to be administered, so nia and the United Kingdom.3 Strategies tion of loading doses and maintenance they do not arrive on the patient to reduce the risk of errors include devel- doses creates complexity in the medication- care unit at the same time. This may oping clinical guidelines and standardiz- use process and can lead to medication help reduce the risk that both doses ing electronic and paper order forms and errors. In Pennsylvania, 580 medical error will be stored near each other on the protocols to guide clinical practice, reduce reports indicating the occurrence of an variation, and improve drug information event associated with the prescribing, communication. NOTES 1. Merriam-Webster Dictionary [online], for acetaminophen overdose. Ann 11. Continuous care throughout patient s.v. “loading dose.” [cited 2012 Jul 6]. Pharmacother 2008 Jun;42(6):766-70. transfer. PA PSRS Patient Saf Advis http://www.merriam-webster.com/ 6. Cottington EM, LaMantia C, Stabler [online] 2005 Dec [cited 2012 Jul 10]. medical/loading%20dose. SP, et al. Adverse event associated with http://patientsafetyauthority.org/ 2. National Patient Safety Agency. methionine loading test: a case report. ADVISORIES/AdvisoryLibrary/2005/ Rapid Response Report NPSA/2010/ Arterioscler Thromb Vasc Biol 2002 Jun dec2(4)/Pages/20.aspx. RRR018: preventing fatalities from 1;22(6):1046-50. 12. Institute for Safe Medication Practices. medication loading doses [online]. 7. Oudin C, Vialet R, Boulamery A, et al. ISMP’s guidelines for standard order 2010 Nov 25 [cited 2012 Jul 6]. http:// Vancomycin prescription in neonates sets [online]. 2010 [cited 2012 Jul www.nrls.npsa.nhs.uk/EasySiteWeb/ and young infants: toward a simplified 5]. http://www.ismp.org/Tools/ getresource.axd?AssetID=92307&type= dosage. Arch Dis Child Fetal Neonatal Ed guidelines/StandardOrderSets.asp. full&servicetype=Attachment. 2011 Sep;96(5):F365-70. 13. Institute for Safe Medication Practices. 3. National Patient Safety Agency. 8. National Coordinating Council for ISMP develops guidelines for standard Rapid Response Report NPSA/2010/ Medication Error Reporting and order sets. ISMP Med Saf Alert Acute RRR018: preventing fatalities from Prevention (NCC MERP). NCC MERP Care 2010 Mar 11;15(5):1-4. medication loading doses: supporting index for categorizing medication 14. Safe intrahospital transport of the information [online]. 2010 Nov [cited errors [online]. 2001 Feb 20 [cited non-ICU patient using standardized 2012 Jul 6]. http://www.nrls.npsa.nhs. 2012 Jul 6]. http://www.nccmerp.org/ handoff communication. Pa uk/EasySiteWeb/getresource.axd? medErrorCatIndex.html. Patient Saf Advis [online] 2009 AssetID=92308&type=full&servicetype= 9. Institute for Safe Medication Practices. Mar [cited 2012 Jul 11]. http:// Attachment. ISMP 2007 survey on high-alert www.patientsafetyauthority.org/ 4. Lamont T, Cousins D, Bischler A, et al. medications: differences between ADVISORIES/AdvisoryLibrary/2009/ Safer loading doses of medicines: nursing and pharmacy perspectives still Mar6(1)/Pages/16.aspx. summary of a safety report from the prevalent. ISMP Med Saf Alert Acute 15. Institute for Safe Medication Practices. National Patient Safety Agency. BMJ Care 2007 May 17;12(10):1-3. Order scanning systems may pull 2011 Jan 26;342(7792):332-4. 10. Institute for Safe Medication multiple pages through the scanner 5. Hayes BD, Klein-Schwartz W, Doyon S. Practices. ISMP’s list of high-alert at the same time, leading to drug Frequency of medication errors medications [online]. 2012 [cited 2012 omissions. ISMP Med Saf Alert Acute with intravenous acetylcysteine Jul 2]. http://www.ismp.org/Tools/ Care 2009 Nov 5;14(22):1-3. highAlertMedications.asp. Page 86 Pennsylvania Patient Safety Advisory Vol. 9, No. 3—September 2012 ©2012 Pennsylvania Patient Safety Authority LEARING OBJECTIVES SELF-ASSESSMENT QUESTIONS — Recognize the most frequently The following questions about this article may be useful for internal education and reported event types involving the assessment. You may use the following examples or come up with your own questions. prescribing, dispensing, and adminis- 1. Which of the following is the most frequently reported type of event associated tering of medication loading doses. with the prescribing, dispensing, and administering of medication loading doses? — Recall causes and contributing fac- a. Loading dose administered at the wrong rate tors associated with the predominant b. Loading dose given multiple times types of events involving the prescrib- c. Loading dose omitted or delayed ing, dispensing, and administering of d. Maintenance dose missed medication loading doses. e. Wrong loading dose given — Identify the most frequently reported medications involved in events 2. Which of the following is a leading factor in omitted or delayed loading dose associated with the prescribing, events in Pennsylvania facilities? dispensing, and administering of a. Pharmacy delivery of the loading dose and maintenance dose(s) to the unit at medication loading doses. the same time — Distinguish between effective and b. Breakdowns when patients were transferred between units within a hospital ineffective strategies to reduce the c. Failure to follow protocol guidance when prescribing, dispensing, or adminis- risk of events involving the prescrib- tering a loading dose ing, dispensing, and administering of d. Omission of an independent double check medication loading doses. e. Limited physical availability of medications requiring loading doses 3. The top four medications involved in events associated with the prescribing, dispensing, and administering of medication loading doses include all of the fol- lowing EXCEPT: a. Acetylcysteine b. Clopidogrel c. HYDROmorphone d. Phenytoin e. Vancomycin The patient was admitted through the emergency department (ED) with seizures. In the ED, the patient received a loading dose of fosphenytoin. The patient was admitted to the intensive care unit (ICU) and, in the ICU, continued to have seizure activity. The physician in the ICU ordered a loading dose of fosphenytoin. After the medication was administered, it was discovered that the patient had already received a loading dose in the ED. The patient received a total of 2,400 mg of fosphenytoin instead of 1,200 mg. Per the physician, it was reported to him that the patient had only received benzodiazepines in the ED. However, alerts did fire in the computer system for “duplicate therapy,” and the first dose was documented in the electronic medication administra- tion record. 4. Select the most appropriate strategy to help prevent this event from reoccurring. a. Differentiate the packaging and labeling of loading doses and maintenance doses to reduce the risk that they may be confused for one another. b. Restrict and limit the physical availability of medications requiring loading doses, as appropriate. c. Standardize electronic and paper order sets and protocols. d. Establish a protocol to guide communication during patient transfers that includes the physician orders implemented pre-transport and those that still need to be executed. e. Develop standardized clinical guidelines on how to prescribe, administer, and monitor loading and maintenance doses. Vol. 9, No. 3—September 2012 Pennsylvania Patient Safety Advisory Page 87 ©2012 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S SELF-ASSESSMENT QUESTIONS (CONTINUED) A physician ordered tigecycline 100 mg intravenous (IV) piggyback statim (stat) followed by an order for tigecycline 50 mg IV piggyback every 12 hours. According to the pharmacy, the loading and maintenance doses were dispensed and delivered to the unit. The nurse inadvertently admin- istered the tigecycline 50 mg IV bag as the initial stat loading dose instead of the tigecycline 100 mg IV bag. 5. Which of the following factors may have contributed to this wrong loading dose event? a. Communication during handoff failed. b. The patient’s loading dose was miscalculated. c. A loading dose of the medication was not required for this patient. d. Tigecycline was available as a floor stock item. e. Pharmacy delivered both the loading dose and maintenance dose to the unit at the same time. 6. Which of the following strategies would be most effective in reducing the risk of this wrong loading dose event? a. Store loading and maintenance doses apart from one another in pharmacy and patient care areas. b. Dispense loading and maintenance doses from pharmacy separately, closer to the time when each one is to be administered. c. Differentiate the package type and design of loading doses and maintenance doses. d. Restrict and limit the physical availability of medications requiring loading doses. e. Develop standardized clinical guidelines on how to prescribe, administer, and monitor loading and maintenance doses. Page 88 Pennsylvania Patient Safety Advisory Vol. 9, No. 3—September 2012 ©2012 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 9, No. 3—September 2012. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2012 by the Pennsylvania Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. This publication is disseminated via e-mail. To subscribe, go to http://visitor.constantcontact.com/ d.jsp?m=1103390819542&p=oi. To see other articles or issues of the Advisory, visit our website at http://www.patientsafetyauthority.org. Click on “Patient Safety Advisories” in the left-hand menu bar. THE PENNSYLVANIA PATIENT SAFETY AUTHORITY AND ITS CONTRACTORS The Pennsylvania Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (“Mcare”) Act. Consistent with Act 13, ECRI Institute, as contractor for the Authority, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the Pennsylvania Patient Safety Authority, see the Authority’s An Independent Agency of the Commonwealth of Pennsylvania website at http://www.patientsafetyauthority.org. ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for more than 40 years, ECRI Institute marries experience and indepen- dence with the objectivity of evidence-based research. 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