Gentamicin double-dosing in Confidential Enquiry into Perioperative Deaths theatre at a Trust using a hybrid prescribing system

Published Date: 22nd September 2021

Publication Authors: Jones B, Saggar A

Background
Gentamicin is commonly used in prophylaxis of peri-operative infection. It has a narrow therapeutic index, necessitating careful dose adjustment, and is usually administered once daily. Patients undergoing emergency surgery may have received gentamicin pre-operatively during resuscitation, conservative management, or treatment of a comorbid infection. At the Trust audited, a hybrid prescribing system combines a digital record with a paper gentamicin chart. Administered doses are charted on paper only. Therefore, there was concerning potential for surgical prophylaxis to be given within 24 h of a previous dose. The aim of this audit was to eliminate potential for harm to patients through excess doses of gentamicin by identifying instances of double-dosing in Confidential Enquiry into Perioperative Deaths (CEPOD) theatre, and identifying means of preventing this from occurring.

Methods
All patients undergoing surgery in CEPOD theatre over a 1-month period were included. Anaesthetic charts for these patients were checked for gentamicin administration. If gentamicin had been given, emergency department casualty cards, electronic records and the patient notes were searched for further administrations of gentamicin within 24 h.

Results
One hundred and fifty patients underwent surgery in CEPOD theatre during the audit window. Of these, 43 patients received intra-operative gentamicin. Six doses (14%) were given to patients who had already received gentamicin within 24 h. Furthermore, three of these 43 patients (7%) were given a second dose of gentamicin within 24 h postoperatively. One patient fell into both groups, receiving three doses within 24 h.

Discussion
Systemic factors in gentamicin prescription format contributed to double-dosing of gentamicin in CEPOD theatre. Factors identified included the inability to document administration time on the digital system, and that the paper gentamicin chart was not routinely brought to theatre with the patient notes, such that it was impossible to check times of previous doses from theatre. In response, it was recommended that the digital system be reformatted to include charting of gentamicin administration time. An alternative recommendation was to ensure paper gentamicin charts accompany patients to theatre. Prospective re-audit will take place after approval of changes. In conclusion, this audit highlighted a pitfall in the hybrid prescribing system, which made it easy to double-dose gentamicin. This may be entirely preventable through simple measures. Approvals.

Jones, B; Saggar, A. (2021). Gentamicin double-dosing in Confidential Enquiry into Perioperative Deaths theatre at a Trust using a hybrid prescribing system. Anaesthesia. 76 (S6), 44

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