PHARM FINAL – SAFETY ALERTS

Exam 1

● Beers Criteria
○ Anticholinergic drugs have been designated as potentially inappropriate for use in
geriatric patients
● Cholinergic Crisis (p. 133)
○ Cholinesterase inhibitor toxicity can cause a life threatening cholinergic crisis.
Common mnemonics can help you identify these potentially dangerous
conditions.
○ Mnemonic 1: SLUDGE and the Killer Bs:
■ Salivation
■ Lacrimation
■ Urination
■ Diaphoresis/diarrhea
■ Gastrointestinal cramping
■ Emesis
■ Bradycardia
■ Bronchospasms
■ Bronchorrhea
○ Mnemonic 2: DUMBELS
■ Diaphoresis/diarrhea
■ Urination
■ Miosis
■ Bradycardia
■ Bronchospasm
■ Bronchorrhea
■ Lacrimation
■ Salivation
● Neuromuscular blocking agents (p. 140)
○ Institute for Safe Medication Practices (ISMP) includes neuromuscular blocking
agents among its list of high-alert medications.
○ High alert medications are those drugs that can cause devastating effects to
patients in the event of a medication error.
● Neuromuscular blocking agents and the patient’s state of consciousness (p. 145)
○ Patients who have been giving a neuromuscular blocking agent may appear
unresponsive due to the drug-induced paralysis; however, they are fully alert and
conscious and can feel pain.
○ It is essential for the nurse to administer prescribed medications such as sedatives
and/or analgesics on a regular basis to prevent undue suffering.
● IV Adrenergic Agonists & Antagonists (p. 150)
○ ISMP includes all IV Adrenergic Agonists & Antagonists among its list of
high-alert meds.
● IV Adrenergic Antagonists → high-alert meds per ISMP (p. 160)
● Older Adult Patients (p. 176)
 ○ Centrally acting alpha agonists (clonidine, guanabenz, guanfacine, methyldopa)
and the adrenergic neuron-blocking agent reserpine have been designated as
potentially inappropriate for use in geriatric patients due to their high risk of
adverse CNS effects, bradycardia, and hypotension.
○ Other drugs are recommended for first-line HTN management in older adult
patients.

Exam 2

Ch. 76
● Compensating for Adrenal Sufficiency
○ When patients have been on prolonged systemic glucocorticoid therapy, the
adrenal glands decrease their endogenous production of glucocorticoids. If
systemic therapy stops suddenly, as when switching from oral therapy to
inhalation therapy, the patient can die. Similarly, during times of severe physical
stress when the body would normally produce high levels of glucocorticoids, if
the dose of systemic glucocorticoids is not increased to meet the increased need,
the patient can die. What important lesson can you take from this? When
discontinuing a systemic glucocorticoid, you must be sure that it is done gradually
to allow the body to resume production of the endogenous hormones. On the other
hand, it's a patient taking systemic glucocorticoids experiences severe physical
stress, such as a motor vehicle crash, or is scheduled for a stressful procedure such
as surgery, you must make certain that the provider remember to prescribe
additional glucocorticoids to supplement for the endogenous hormone that the
patient cannot produce .
● Too much of a good thing (SABAs)
○ Short-acting beta 2 agonists are often life saving medications. If they are taken in
excess, however, overdose can lead to dangerous adverse effects such as
tachydysrhythmias, angina, and seizures. Cardiac arrest & death may occur. If
your patient needs to use a rescue inhaler more than twice a week to control
asthma symptoms, it is time to step up therapy.
Ch. 90
● Antitubercular drugs
○ Drugs used to treat tuberculosis may cause severe liver injury. Fatalities have
been reported. Nurses should routinely monitor for signs & symptoms of liver
damage.
● Amikacin, streptomycin, and capreomycin
○ Capreomycin and the aminoglycosides amikacin and streptomycin are ototoxic.
Vertigo may occur as a result of vestibular injury. Hearing loss may be permanent.
These drugs are also nephrotoxic and may cause renal impairment

Exam 3

Ch. 18
● IV adrenergic antagonists
 ○ All IV adrenergic antagonists are on the list of high-alert medications. High-alert
medications can cause devastating effects to patients in the event of a medication
error.
Ch. 19
● Older Adults Patients
○ Centrally acting alpha 2 agonists (clonidines, guanabenz, guanfacine,
methyldopa) and the adrenergic neuron blocking agent reserpine have been
designated as potentially inappropriate for use in geriatric patients due to their
high risk of adverse CNS effects, bradycardia, and hypotension. Other drugs are
recommended for first line hypertension management in older adult patients.
Ch. 41
● Furosemide
○ Use of furosemide can produce excessive loss of sodium, chloride, and water.
Severe dehydration can result. Dehydration can promote hypotension, thrombosis,
and embolism.
Ch. 44
● ACE Inhibitors
○ ACE inhibitors can cause angioedema, a potentially life-threatening reaction. If
patients report edema of the tongue, lips, or eyes, emergency care should be
immediately, and the patient must never take ACE inhibitors again.
Ch. 45
● Immediate-release nifedipine
○ Immediate-release nifedipine has been associated with increased mortality in
patients with myocardial infarction and unstable angina. Other IR CCBs (calcium
channel blockers) have been associated with an increased risk of myocardial
infarction and patients with hypertension. However, in both cases, a causal
relationship has not been established. Nonetheless it's recommended that
immediate-release nifedipine, especially in higher doses, be used with great
caution, if at all. It is important to note that these adverse effects have not been
associated with sustained-release nifedipine or with any other long-acting CCB.
Ch. 46
● Falls
○ Vasodilators place patients at increased risk of falls. Patients receiving vasodilator
should be informed about symptoms of hypotension (lightheadedness, dizziness)
and advised to sit or lie down if these occur. Failure to follow this advice. Patients
should also be taught that they can minimize hypotension by avoiding abrupt
transitions from a supine or seated position to an upright position.

Exam 4

Ch. 49
● Antidysrhythmic Drugs
○ All of these drugs can worsen existing dysrhythmias and generate new ones.
Regardless of the particular circumstances of drug use, all pts must be followed
closely. Of the mechanisms by which drugs can cause dysrhythmias, one deserves
special mention: prolongation of the QT interval. Drugs that prolong the QT
interval increase the risk of torsades de Pointes, a dysrhythmias that can progress
 to fatal ventricular fibrillation. All class IA and class III agents cause QT
prolongation, and so must be used with special caution.
■ Class IA: Quinidine, Procainamide, Disopyramide
■ Class III: Potassium Channel Blockers (K+ channel blockers)
● Amiodarone (Cordarone, Pacerone)
● Dronedarone (Multaq)
● Sotalol (Betapace, Betapace AF)
● Dofetilide (Tikosyn)
● Ibutilide (Corvert)
Ch. 51
● Phosphodiesterase type 5 inhibitors (PDE5 inhibitors)
○ PDE5 inhibitors – sildenafil (Viagra), tadalafil (Cialis), avanafil (Stendra), and
vardenafil (Levitra) – are used for erectile dysfunction. All of these drugs can
greatly intensify nitroglycerin-induced vasodilation. Life-threatening
hypotension can result. Accordingly, concurrent use of PDE5 inhibitors with
nitroglycerin is absolutely contraindicated.
Ch. 53
● Increased Risk for Bleeding
○ All of the anticoagulant and antiplatelet drugs mentioned increase the risk for
bleeding. The nurse must be diligent in assessing for and reporting any signs and
symptoms of bleeding, including decreased level of consciousness, painful or
swollen joints, oozing gums, hematuria, or decrease in platelet or hemoglobin
values.

Exam 5

● Penicillins are the most common cause of drug allergy

○ Between 0.4% and 7% of patient who receive penicillins experience an allergic
reaction
○ Severity can range from minor to life threatening
● Tetracyclines can cause permanent tooth discoloration , tetracycline should not be given
to pregnant women and breastfeeding women or to children younger than 8 years
● Clindamycin can cause potentially fatal Clostridium difficile diarrhea. Patient should
promptly report any diarrhea to their healthcare provider
● Aminoglycoside Ototoxicity
○ Patients on aminoglycoside therapy should be monitored for ototoxicity.
○ The first sign of impending cochlear damage is high pitch tinnitus or ringing in
the ears.
○ Ototoxicity is largely irreversible
○ If permanent injury is to be avoided, aminoglycosides should be withdrawn in the
first set of damage (i.e. tinnitus, persistent headache, or both)
● Aminoglycoside induced neuromuscular blockade
○ Aminoglycosides can inhibit neuromuscular transmission, causing flaccid
paralysis and potentially fatal respiratory depression
○ Most episodes of neuromuscular blockade have occurred following intraperitoneal
or intrapleural installation of aminoglycosides
 ○ However neuromuscular blockade has also occurred with IV, IM and oral dosing
● Sulfonamides & G6PD Deficiency
○ Sulfonamides may cause significant hemolysis if prescribed to patients with
G6PD deficiency, and inherited trait
● Myasthenia Gravis
○ Ciprofloxacin and other fluoroquinolones can exacerbate muscle weakness in
patients with myasthenia gravis
○ Accordingly patients with a history of myasthenia gravis should not receive these
drugs
● Amphotericin
○ Infusion of amphotericin may be associated with delirium, hypotension,
hypertension, wheezing, and hypoxia
○ Rarely, and amphotericin causes rash, seizures, anaphylaxis, dysrhythmias, acute
liver failure, and nephrogenic diabetes insipidus
● Hazardous drugs requiring special handling
○ Trifluridine
○ Ganciclovir
○ Valganciclovir
○ Cidofovir
○ Entecavir
○ Ribavirin
● Cidofovir
○ Cidofovir has been associated with severe renal impairment
○ Dialysis have been required after only one or two doses
○ Monitoring for renal function is an important nursing function
● Before administering a vaccination, it is important to question the patient or family
member about allergies, previous reactions to vaccines, and current health status

Exam 6

Ch 52
● All anticoagulants, antiplatelet, and thrombolytic drugs increase the risk of patient
bleeding. Careful assessment of mental status, blood pressure, heart rate, and mucous
membrane should be completed to assess for internal bleeding
Ch 21
● Beers Criteria.
○ Anticholinergic drugs have been designated as potentially inappropriate for use in
geriatric patients. The anticholinergic most commonly prescribed for management
of Parkinson's disease are benztropine (Cogentin) and trihexyphenidyl
Ch 24
● Antiepileptic drugs and oral contraceptives.
○ 8 AEDs - carbamazepine, eslicarbazepine, lamotrigine, oxcarbazepine, phenytoin,
phenobarbital, rufinamide, and topiramate -- decrease the effectiveness of oral
contraceptives. 4 of these -- carbamazepine, phenytoin, phenobarbital, and
Topiramate -- are associated with harm to the human fetus. If it is necessary to
 prescribe any of these drugs, it is important to advise patients of the risks and the
need for additional contraceptives pregnancy if not desired.
● IV administration of phenytoin
○ the chemical and pharmacodynamic properties of phenytoin present unique
challenges for intravenous administration. These can be managed through safe
Administration.
■ to prevent development of significant hypertension and cardiac
dysrhythmias during IV administration of phenytoin, Administration
should not exceed 50 mg/min in adults or either 1-3 mg/kg/min or 50
mg/min (Whichever is slower) in children. Cardiac Rhythm should be
monitored during Administration
■ phenytoin should never be mixed with or piggybacked on dextrose
Solutions. Instead, it should be given directly into a large vein. Product
labeling recommends flushing with saline both before and following
intravenous administration
■ phenytoin can cause severe tissue damage if the solution infiltrates the
area surrounding the IV site. The risk can be decreased by initiating
infusion in a large peripheral or Central vein. Close monitoring for
extravasation is essential.
● Intravenous administration of fosphenytoin
○ if the rate of fosphenytoin administration exceeds 150 mg phenytoin equivalents
(PE) per minute, severe hypotension and cardiac arrhythmias may occur. Cardiac
monitoring is needed when administering this drugs
● Multiple formulations of Gabapentin
○ two forms of Gabapentin are not currently indicated for management of epilepsy
and, therefore, should not be confused with the form of Gabapentin known as
Neurontin.
○ Gabapentin ER (Gralise) is approved for management of postherpetic neuralgia
○ Gabapentin enacarbil ( Horizant), a prodrug form of Gabapentin, is approved for
treatment of moderate to severe restless leg syndrome
○ Owing to differences in pharmacokinetics, these forms of Gabapentin are not
interchangeable with each other or with Neurontin
● Management of epilepsy during pregnancy
○ The risk to a fetus from uncontrolled seizures is greater than the risk from a
AEDs. Therefore, patients with major seizure disorder should continue to take
AEDs throughout pregnancy. To minimize fetal risk, the lowest effective dose
should be used whenever possible.
○ To reduce the risk of neural tube defects that can occur with AEDs, pregnant
patients should take supplemental folic acid before conception and throughout
pregnancy. A dose of 2mg/day has been recommended.
○ Maternal and fetal/infant bleeding risks are also a concern. Phenobarbital,
phenytoin, carbamazepine, and primidone reduce levels of vitamin K-dependent
clotting factors by inducing hepatic enzymes, increasing the risk of bleeding. To
reduce the risk pregnant patients should be given 10 mg vitamin K daily during
the last few weeks of pregnancy, and the fetus should be given a 1-mg IM
injection of vitamin K at birth.
CH 30
● Serotonin Receptor Agonists
○ Serotonin receptor agonists can cause vasoconstriction and coronary vasospasm.
These drugs should not be administered to patients with coronary artery disease,
current symptoms of angina, or uncontrolled hypertension.

Exam 7

Ch. 25
● Manifestations of Serotonin Syndrome
Manifestations of Serotonin Syndrome

System Manifestation

Agitation, restlessness, confusion,

Central Nervous System
hallucinations, headache, unconsciousness

Hyperthermia, diaphoresis, blood pressure

Autonomic Nervous System
elevation, tachycardia, pupil dilation

Tremors, hyperreflexia, ataxia, muscle

Neuromuscular System
twitching, muscle rigidity, seizures

Gastrointestinal System Nausea, vomiting, diarrhea

● Centrally acting muscle relaxants

○ The CNS depressant effects of centrally acting muscle relaxants may cause
severe drowsiness initially.
○ Patients should be advised not to drive or engage in activities that may be
hazardous as long as these effects persist.
Ch. 73
● Methotrexate
○ Methotrexate can cause numerous and potentially fatal toxicities of the bone
marrow, liver, lungs, and kidneys.
○ Other fatalities have occurred associated with skin reactions and due to
hemorrhagic enteritis and gastrointestinal perforation.
● Tumor Necrosis Factor Antagonists
○ Patients taking TNF antagonists (adalimumab, certolizumab pegol, etanercept,
golimumab, and infliximab) are at an increased risk of developing serious
systemic infections and sepsis.
○ Children and adolescents taking TNF antagonists have developed malignancies.
Ch. 74
● NSAIDs
○ NSAIDs may increase the risk for myocardial infarction, stroke, and other
thromboembolic events.
○ NSAIDs also increase the risk for dangerous gastrointestinal adverse effects, such
as bleeding, ulceration, and perforation.
 ● Pegloticase (Krystexxa)
○ Anaphylaxis and infusion reactions may occur.
○ These typically occur within 2 hours after infusion but may be delayed.
○ Premedicate with an antihistamine and a glucocorticoid, and monitor patients
closely during the infusion.
Ch. 31
● Extrapyramidal symptoms
○ For many patients, EPS are uncomfortable, disturbing, and sometimes, dangerous.
○ Some manifestations of EPS, such as tardive dyskinesia, or irreversible.
○ It is crucial for the RN to monitor patients treated with antipsychotic medications
for evidence of EPS, and to report this immediately if present.
● Neuroleptic malignant syndrome
○ Neuroleptic malignant syndrome can be fatal if not treated promptly.
○ The RN must recognize the signs and symptoms of NMS and report them
immediately.
○ Treatment with dantrolene and bromocriptine may be ordered by the provider.
Ch. 32
● Suicide Risk
○ Antidepressants may increase the risk of suicide in depressed patients, especially
during the early phase of treatment.
○ The risk of antidepressant-induced suicide is greatest among children,
adolescents, and young adults.
○ Patients starting treatment or changing doses must be monitored closely for
suicidal behavior.
Ch. 36
● Amphetamines
○ Amphetamines have a high potential for abuse and dependence.
○ In patients who use amphetamines chronically, withdrawal may occur if use of
these medications is suddenly stopped.

Exam 8

Ch. 58
● Agranulocytosis (with Methimazole -- drug for hyperthyroidism)
○ AGranulocytosis is a serious condition characterized by a dramatic reduction in
circulating granulocytes, a type of white blood cell needed to fight infection. The
reaction is rare (about 3 cases per 10,000) patients and usually develops during
the first 2 months of therapy. Sore throat and fever may be the earliest indication,
and patients should be instructed to report it immediately. Because a
granulocytosis often happens rapidly, periodic blood count cannot guarantee early
detection
Ch. 59
● Cardiovascular Effects of Vasopressin
○ Because of its powerful vasoconstriction actions, vasopressin can cause severe
adverse cardiovascular effects. (Despmopressin is a weak pressor agent and hence
does not adversely affect hemodynamics.) By constricting arteries of the heart,
 vasopressin can cause angina pectoris and even myocardial infarction – especially
in patients with coronary insufficiency. In addition, vasopressin may cause
gangrene by decreasing blood flow in the periphery. Because it can reduce cardiac
perfusion, vasopressin must be used with extreme caution in patients with
coronary artery disease.
Ch. 60
● Stress & Glucocorticoids (GCS)
○ At times of stress, patients must increase their glucocorticoid dosage. Failure to
increase the dosage can be fatal.
Ch. 78
● Diarrhea
○ In retrospective, observational studies, Omeprazole and other PPIS have been
associated with a dose-related increase in the risk of infection with C. difficile, a
bacterium that can cause severe diarrhea. Patients experiencing diarrhea while
taking omeprazole or other PPIs should report immediately to their healthcare
provider for testing.
● Misoprostol in pregnancy
○ Misoprostol is contraindicated during pregnancy.The drug is classified in FDA
pregnancy risk category X: the risk of use by pregnant women clearly outweighs
any possible benefits. Because prostaglandins stimulate uterine contractions, the
use of misoprostol during pregnancy has caused partial or complete expulsion of
the developing fetus.
Ch. 80
● Droperidol
○ Droperidol may pose a risk of fatal dysrhythmias owing to prolongation of the QT
interval. Accordingly, patient receiving the drugs to undergo an
electrocardiographic evaluation before administration
● Glucocorticoids (GCS)
○ Prolonged use of glucocorticoids can cause severe adverse effects, including
adrenal suppression, osteoporosis, increased susceptibility to infection, and a
cushingoid syndrome.

Exam 9

Ch. 27
● Malignant Hyperthermia
○ Malignant hyperthermia, while rare, can be fatal. Administration of inhaled
anesthetics with the neuromuscular blocker succinylcholine can increase this risk
in genetically predisposed individuals. If malignant hyperthermia is present in a
patient's family medical history, it is imperative to relay this information to the
anesthetist or the team performing surgery.
Ch. 28
● Respiratory Arrest
○ Opioid medications can cause respiratory arrest in both opioid naive and opioid
tolerant patients. Monitor level of consciousness, respiratory rate, and oxygen
saturation in patients receiving opioid medications. When administering opioids,
assess initial vital signs and withhold medication and notify the provider if the
 patient has a decreased level of consciousness or respiratory rate less than 12
breaths per minute.
Ch. 34
● Barbiturates
○ Barbiturates are powerful respiratory depressants that can be fatal in overdose.
Respiratory depression does NOT decrease with drug tolerance.
Ch. 35
● Benzodiazepines
○ Benzodiazepines can cause physical dependence, which can make withdrawal
extremely hard for some patients/ the difficulty is that withdrawal produces
intense anxiety, which people with panic disorder may find intolerable. To
minimize withdrawal symptoms, benzodiazepines should be withdrawn very
slowly – over a period of several months.
Ch. 71
● Aspirin
○ The use of aspirin in children younger than 18 years is associated with Reye’s
syndrome.
● First Generation NSAIDs
○ All first generation NSAIDs are associated with increased risk of GI bleeding that
can lead to hospitalization or death.

--------

No safety alerts for diabetes chapter