Multi-Incident Analysis of near-miss incidents of alteplase and tenecteplase mix-up in Hyperacute Stroke Care (5404)

Objective: To describe the frequency and factors contributing to near-miss incidents of alteplase and tenecteplase mix-up in Code Strokes at a large tertiary hospital. Background: An institutional retrospective audit (2014–2019) identified 28 incidents where alteplase and tenecteplase were dispensed (via automated dispensing cabinet (ADC)) for the same patient during a code stroke. It did not appear that any patient actually received an incorrect medication. However, due to the high number of cases and high-risk nature of tissue plasminogen activators, near-miss events must be addressed to prevent recurrence and potential morbidity and mortality. Design/Methods: Retrospective audits from 2014–2019 provided information and frequency associated with near –miss incidents. A qualitative multi-incident analysis (MIA) approach consisting of semi-structured interviews with nurses involved with processes, determining main themes, and identifying potential contributing factors was conducted. 11 interviews were completed (5 nurses directly involved with an incident, 6 others familiar with alteplase administration during Code Stroke) by a single analyst. Two independent analysts determined main themes. Results: Amongst code stroke patients at Sunnybrook Hospital 28 incidents were identified as representing dispensing error (4.35%). Key themes from the MIA included: Use of dangerous abbreviations, Sound-alike and look-alike drug names. Contributing factors included: cultural norm to refer to alteplase as TPA, location of storage, familiarity with brand/generic names and confirmation bias. An interdisciplinary team identified potential contributing factors and suggested recommendations. Conclusions: Near-miss errors occurred at a higher than expected rate despite use of an ADC and key themes identified in our study are reflected in factors reported by national drug safety agencies. This highlights the importance of this topic in hyperacute stroke care. Leveraging recommendations such as separating storage of the medications, user interface prompting confirmation of indication at time of dispensing, in addition to provider education are key facets to preventing future errors. Disclosure: Dr. Lam has nothing to disclose. Dr. Teo has nothing to disclose. Dr. Tonna has nothing to disclose. Dr. Wong has nothing to disclose. Dr. Madorin has nothing to disclose. Dr. Khosravani has nothing to disclose.