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LETTER TO THE EDITOR

Clinical Protocols and Conditioned Human Behavior in the Background of Inadequate Information as a Risk Factor for Development of Critical Incidents

Department of Anesthesiology; Henry Ford Hospital; Detroit, Michigan; hkroll1{at}hfhs.org

In Response:

Jayaram and Mathew (1) raise important comments regarding our case report (2). It is the policy of our hospital and the Joint Commission on the Accreditation of Healthcare Organizations that after a sentinel event a root cause analysis is completed (3). As an outcome of the analysis, several areas of process improvement were identified and initiated:

1. System-wide accessible electronic documentation of all patient encounters in the dialysis suite.
   
2. Contraindication to the initiation of the tight glycemic control protocol in patients requiring peritoneal dialysis with icodextrin.
   
3. The placement of "Do not use for continuous ambulatory peritoneal dialysis patients" warning labels on all hospital glucometers.
   
4. Creation of a multidisciplinary "hand-off/transfer" document to follow the patients throughout their hospitalization.
   
5. Improved patient educational materials to facilitate the patient's ability to alert healthcare workers to the potential problems associated with icodextrin.
   

Jayaram and Mathew (1) are correct in stating that "the patient's own home glucometer (One Touch Profile; Lifescan, Milpitas, CA) is approved by the FDA to be used in her condition of diabetes with concomitant chronic renal failure requiring peritoneal dialysis with icodextrin." However, their suggestion that "any device except those working on glucose dehydrogenase pyrroloquinolequinone (GDH-PQQ) is safe," (1) is inaccurate. A study carried out by Janssen et al. (4) demonstrated positive interference from maltose metabolites in many glucometers, not just those glucometers which utilize GDH-PQQ reagent strips. In their study, they were able to show that a number of glucometers utilizing glucose oxidase test strips were subject to variable levels of maltose metabolite interference (4). Although the systems employing GDH-PQQ appear to suffer from the most interference from maltose metabolites, it is potentially dangerous to assume that all analyzers utilizing alternative enzyme reagent systems are safe (4–6). Additionally, Oyibo et al. (5) recommends that "all analyzers must be cross-checked with the laboratory reference method before use in these patients."

REFERENCES

1. Jayaram R, Mathew A. Clinical protocols and conditioned human behaviour in the background of inadequate information as a risk factor for development of critical incidents. Anesth Analg 2007;104:1511–2
2. Kroll H, Maher T. Significant hypoglycemia secondary to icodextrin peritoneal dialysate in a diabetic patient. Anesth Analg 2007;104:1473–4[Abstract/Free Full Text]
3. Joint Commission on the Accreditation of Healthcare Organizations Sentinel Event Policy and Procedures. Available at: http://www.jointcommission.org/NR/rdonlyres/690008c7-EAB2-4275-BC7B-68B37481D658/0/SE_Chap_Sept06.pdf
4. Janssen W, Harff G, Caers M, Schellekens A. Positive interference of icodextrin metabolites in some enzymatic glucose methods. Clin Chem 1998;44:2379–80[Free Full Text]
5. Oyibo SO, Pritchard GM, Mclay L, James E, Laing I, Gokal R, Boulton AJ. Blood glucose overestimation in diabetic patients on continuous ambulatory peritoneal dialysis for end-stage renal disease. Diabetic Med 2002;19:693–6[Web of Science][Medline]
6. Mehmet S, Quan G, Thomas S, Goldsmith D. Important causes of hypoglycemia in patients with diabetes on peritoneal dialysis. Diabetic Med 2001;18:679–82[Web of Science][Medline]

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