Topic name: Part-I: Illustrate the common medication errors occur in a hospital

with the prevention and management procedure.

Part-II: Differentiate between poisoning and toxicities with proper explanation

and management.

Course title: Hospital And Community Pharmacy

Course code: BPH-4017

Submission date: 27.07.21

Submitted to, Submitted by,

Yesmin Begum Name: Rajia Sultana
Assistant Professor ID: 2018000300099
Department of Pharmacy Batch: 31
Southeast University Section: C

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 Content

Topic name Page number

1. Introduction of Medication error 2

2. Definition of medication error 3-4

3. Medication errors examples 4

4. Types of medication error and prevention 4-11

5. Guideline on Safe Use of High Alert 12-15

Medications
6. Guide on handling look-Alike & Sound- 15-17
Alike Medications
7. Definition of poisoning and toxicity 18

8. Types of poison and toxin

18-20
9.Pathways of poison and toxin 20

10.Mechanism of poisoning and toxicity 20-22

11. Diagnosis of Poisoning and toxicity 22-23

12. Treatment of Poisoning and toxicity 23-27

13.Prevention of Poisoning and toxicity 27

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Part-I: Illustrate the common medication errors occur in a hospital with the
prevention and management procedure.

Introduction
Medical errors are a silent and largely unseen tragedy. Estimates suggest that medical errors and
other instances of preventable harm at hospitals result in the death of 210,000 to 440,000
Americans each year. A 2013 study by the Inspector General of the Department of Health and
Human Services (DHHS) identified 180,000 deaths related to medical error in 2010, of which
44% were determined clearly or likely preventable.

Based on these figures, medical errors are the third leading cause of death in America, after heart
disease and cancer. Beyond the obvious emotional toll, unexpected adverse effects related to
medical error increase personal and institutional financial burdens, adding estimated billions of
dollars to health care costs annually. To learn more about how, when, and why medical errors
occur, federal regulations established in 2003 required hospitals participating in the Medicare
program to, “track medical errors and adverse patient events, analyze their causes, and
implement preventive actions and mechanisms that include feedback and learning throughout the
hospital.” Hospitals report this information using a federally-approved Quality Assessment and
Performance Improvement (QAPI) program.

While reporting has been compulsory since 2003, survey data presented by the DHHS Office of
the Inspector General in 2012 found that-

 Only about 14% of “patient harm events” experienced by Medicare beneficiaries were
captured by hospital incident reporting systems
 An estimated 86% of total incidents were not reported.
 Of the unreported incidents, 62% were not reported because staff members did not
perceive them as reportable.
 25% of the unreported incidents were described as commonly reported but not reported in
these cases.
 Events were most often reported by nurses who identified them as part of the regular
course of care. [1]

Definition of Medication error

A medication error is defined as "any preventable event that may cause or lead to inappropriate
medication use or patient harm while the medication is in the control of the healthcare
professional, patient, or consumer,” according to the National Coordinating Council for
Medication Error Reporting and Prevention.

Medication errors can occur throughout the medication-use system. Such as, when prescribing a
drug, upon entering information into a computer system, when the drug is being prepared or
dispensed, or when the drug is given to or taken by a patient. [2]

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 [3]

Medication errors examples:

1. Omissions – any prescribed dose not given

2. Wrong dose dispensed or administered – too much or too little
3. Extra dose given
4. Given wrong medicine
5. Wrong dose interval
6. Wrong administration route – administration of a medicine by a different route or in a
different form from that prescribed
7. Wrong time for administration
8. Not following warning’ advice when administering. Take with or after food.
9. Prescribed or administrated of a medicine to which the resident has a known allergy
10. Dispensed or administrated an expiry date medicine
11. Un-prescribed medicine — dispense or administrate authorized medicine to a patient.

Types of medication error and prevention

Medication errors can occur at many steps in patient care, from ordering the medication to the
time when the patient is administered the drug. In general, medication errors usually occur at one
of these points:

 Ordering/prescribing
 Documenting
 Transcribing
 Dispensing
 Administering
 Monitoring

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Medication errors are most common at the ordering or prescribing stage. Typical errors include
the healthcare provider writing the wrong medication, wrong route or dose, or the wrong
frequency. These ordering errors account for almost 50% of medication errors. Data show that
nurses and pharmacists identify anywhere from 30% to 70% of medication-ordering errors. It is
obvious that medication errors are a pervasive problem, but the problem is preventable in most
cases.

Types of Medication Errors in hospital

 Prescribing
 Omission
 Wrong time
 Unauthorized drug
 Improper dose
 Wrong dose prescription/wrong dose preparation
 Administration errors including the incorrect route of administration, giving the drug to
the wrong patient, extra dose or wrong rate
 Monitoring error such as failing to take into account patient liver and renal function,
failing to document allergy or potential for drug interaction
 Compliance error such as not following protocol or rules established for dispensing and
prescribing medications 

Let’s talk about these in detail-

1. Prescribing Errors

Prescribing errors may be defined as the incorrect drug selection for a patient. Such errors can
include the dose, quantity, indication, or prescribing of a contraindicated drug. Lack of
knowledge of the prescribed drug, its recommended dose, and of the patient details contribute to
prescribing errors. Other contributing factors include:
 Illegible handwriting.
 Inaccurate medication history taking.
 Confusion with the drug name.
 Inappropriate use of decimal points.
A zero should always precede a
decimal point (e.g. 0·1). Similarly,
tenfold errors in dose have occurred
as a result of the use of a trailing
zero (e.g. 1·0).
 Use of abbreviations (e.g. AZT has
led to confusion between zidovudine
and azathioprine).
 Use of verbal orders.

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Risk factors for the development of prescribing errors such as work environment, workload,
whether prescribing for own patient, communication within the team, physical and mental
wellbeing, and lack of knowledge were all identified. Organizational factors such as inadequate
training, low perceived importance of prescribing, a hierarchical medical team, and an absence of
self-awareness of errors also contributed to these errors. Electronic prescribing may help to
reduce the risk of prescribing errors resulting from illegible handwriting, although it can in turn
lead to further problems such as incorrect drug selection. Computerized physician order entry
systems eliminate the need for transcription of orders by nursing staff and for interpretation of
orders by pharmacy staff and have been shown to have a significant effect on reducing
medication errors.

2. Dispensing Errors

Dispensing errors occur at any stage of the dispensing process, from the receipt of the
prescription in the pharmacy to the supply of a dispensed medicine to the patient. Dispensing
errors occur at a rate of 1–24 % and
include selection of the wrong
strength or product. This
occurs primarily with drugs that have
a similar name or appearance.
Lasix® (frusemide) and Losec®
(omeprazole) are examples of
proprietary names which, when
handwritten, look similar and further
emphasize the need to prescribe
generically. Other potential
dispensing errors include wrong
dose, wrong drug, or wrong patient
and the use of computerized labelling
has led to transposition and typing errors which are among the most common causes of
dispensing error.
Approaches to reducing dispensing errors include:
 Ensuring a safe dispensing procedure.
 Separating drugs with a similar name or appearance.
 Keeping interruptions in the dispensing procedure to a minimum and maintaining the
workload of the pharmacist at a safe and manageable level.
 Awareness of high risk drugs such as potassium chloride and cytotoxic agents.
 Introducing safe systematic procedures for dispensing medicines in the pharmacy.

3. Wrong Time Errors

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In both home and institutional settings, it is challenging to be completely accurate with
scheduled doses. The concern is that some medications absorption is significantly altered if taken
with or without food. As such, it is important to adhere to scheduled times as commonly; this
may lead to under or overdosing.

4. Unauthorized Drug Errors

Administration to the patient of a medication dose not authorized for the patient. This category
includes a dose given to the wrong patient, duplicate doses, administration of an unordered drug,
and a dose given outside a stated set of clinical variables (e.g., medication order to administer
only if the patient's blood pressure falls below a predetermined level).

5. Improper Dose Errors

This error includes overdose, underdose, and an extra dose. An incorrect dose occurs when an
inappropriate or different medication dose is given other than what was ordered, errors of
omission when a scheduled dose of medication is not given, and when a drug is given via an
incorrect route. Errors due to incorrect routes usually occur due to unclear labeling or tubing that
is adaptive to multiple connectors/lines of access. Incorrect routes often result in result in
significant morbidity and mortality.

6. Wrong Drug Preparation Errors

This error usually occurs with compounding or some other type of preparation before the final
administration. An example is choosing the incorrect diluent to reconstitute.[4]

7. Wrong Administration Technique Errors

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Situations when the drug is given via the correct route, site and so forth, but improper technique
is used. Examples are not using Z tract injection technique when indicated for a drug, incorrect
instillation of ophthalmic ointment, and incorrect use of an administrative device.
8. Deteriorated Drug Errors

Administration of a medication when the physical or chemical integrity of the dosage form has
been compromised, such as expired medications, medications not properly stored, or medications
requiring refrigeration that are left out at room temperature.

9. Monitoring Errors

This error occurring as a result of the inappropriate monitoring of therapeutic and/or adverse
effects and failure to monitor labs. A high-risk example would be giving warfarin when the
patient’s international normalized ratio is found to be significantly elevated, which may result in
excessive bleeding.
Monitoring errors may be categorized as follows:
 Failure to monitor medication effects
 Incorrect interpretation of laboratory data used
to monitor medication effects
 Incorrect transcription of laboratory test values
 Incorrect timing of monitoring
 Incorrect timing of serum concentration
monitoring.

10. Compliance Errors

Errors occurring as a result of a patient failing to

take medications as prescribed. [5]

Causes of Medication Errors

 Expired Product

Usually occurs due to improper storage of preparations resulting in deterioration or use of

expired products.

 Incorrect Duration

Duration errors occur when medication is received for a longer or shorter period of time than
prescribed.

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  Incorrect Preparation

This error usually occurs with compounding or some other type of preparation before the final
administration. An example is choosing the incorrect diluent to reconstitute.

 Incorrect Strength

Incorrect strength may potentially occur at many points in the medication process. It usually
occurs due to human error when similar bottles or syringes with the incorrect strength is selected.

 Incorrect Rate

Most often occurs with medications that are given as IV push or infusions. This is particularly
dangerous with many drugs and may result in significant adverse drug reactions. Examples
include tachycardia due to rapid IV epinephrine or red man syndrome due to the rapid
administration of vancomycin.

 Incorrect Timing 

In both home and institutional settings, it is challenging to be completely accurate with

scheduled doses. The concern is that some medications absorption is significantly altered if taken
with or without food. As such, it is important to adhere to scheduled times as commonly; this
may lead to under or overdosing.

 Incorrect Dose

This error includes overdose, underdose, and an extra dose. An incorrect dose occurs when an
inappropriate or different medication dose is given other than what was ordered, errors of
omission when a scheduled dose of medication is not given, and when a drug is given via an
incorrect route. Errors due to incorrect routes usually occur due to unclear labeling or tubing that
is adaptive to multiple connectors/lines of access. Incorrect routes often result in result in
significant morbidity and mortality.

 Incorrect Dosage Form

This occurs when a patient receives a dosage form different than prescribed, such as immediate-
release instead of extended-release.

 Incorrect Patient Action

This occurs when a patient takes a medication inappropriately. Patient education is the only way
to prevent this type of error.

 Known Contraindication

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This occurs when medications are not vigilantly reviewed for drug-drug, drug-disease, or drug-
nutrient interactions.

 Pharmacist

Errors by pharmacists are usually judgmental or mechanical. Judgmental errors include failure to

detect drug interactions, inadequate drug utilization review, inappropriate screening, failure to
counsel the patient appropriately, and inappropriate monitor. A mechanical error is a mistake in
dispensing or preparing a prescription, such as administering an incorrect drug or dose, giving
improper directions, or dispensing the incorrect dose, quantity, or strength.

The most common causes involve workload, similar drug names, interruptions, lack of support
staff, insufficient time to counsel patients, and illegible handwriting.

Pharmacy Error Prevention

Many adverse drug events are preventable, as they are often due to human error. Common causes
of error related to the pharmacists include failure to:

 Deliver the correct dosage

 Identify contraindication to drug therapy.
 Identify a drug allergy.
 Monitor drugs with narrow therapeutic indexes
 Recognize drug interaction
 Recognize knowledge deficits

Often these errors can be avoided by spending time talking speaking to the patient and double-
checking their understanding of the dose, drug allergies, and reviewing any other medications
they may be taking. Barriers to successful communication include the inability to reach
prescribers, unclear verbal and written orders and time constraints make it challenging to check
drug interactions. A pharmacist's responsibilities often include supervising patients' medication
treatment and notifying the healthcare team when a discrepancy is found. Most medication
discrepancies are found at discharge, highlighting the need for a pharmacist to assist in the
discharge process.

 Illegible Writing

Illegible writing has plagued both nurses and pharmacists for decades. Physicians are often in a
hurry and frequently scribble down orders that are not legible; this often results in major
medication mistakes. Taking shortcuts in writing drug orders is a prescription for a lawsuit.
Often the practitioner or the pharmacist is not able to read the order and makes their best guess.
If the drug required is a dire emergency, this also adds more risk to the patient. To eliminate such

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errors, most hospitals have rules that practitioners and pharmacists have to follow; if the drug
order is illegible, the physician must be called and asked to rewrite the order clearly. The
practitioner or the pharmacist should never guess what the drug/dose is. The bad writing by
physicians has become such a major problem that the Institute of Safe Medication Practices has
recommended the complete elimination of handwritten orders and prescriptions. This problem
has been resolved using electronic records where everything is typed, and poor writing is no
longer an issue; however, errors still can occur from writing the wrong drug, dose, or frequency.

Preventing Medication Errors

 Always write one prescription for each medication.

 Besides signing the prescription, always circle your name on the preprinted prescription
pad.
 Do not hesitate to check the dose and frequency if you are not sure.
 Always consider the fact that each medication has the potential for adverse reactions.
 Do not use drug abbreviations when writing orders.
 Always add the patient’s age and weight to each prescription.
 Check for liver and renal function before ordering any medication.
 Spell out the frequency and route of dosage; do not use abbreviations.
 Always specify the duration of therapy; do not say give out "XXX" number of pills.
 Always be aware of high-risk medications.
 When writing a prescription, state the condition being treated. [6]

Guideline on Safe Use of High Alert Medications

Hospitals and healthcare providers aim to provide high quality and safe medical care to their
patients, including the safe and effective use of medications.

These medications, however, can be compared to a two-edged sword: while useful, they can also
be harmful as a result of errors associated with their use as well as from adverse events/effects
especially with these medications that have a very narrow margin of safety and can cause severe
harm to the patient.

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 Figure: Key Steps for Ensuring Medication Safety

These medications are recognized as High Alert Medications.

The Institute for Safe Medication Practices has gathered a list of “high-alert” medications. These
medications require extra precaution because they have highly potentially rich to the patient
when used in error.

 Objectives

This guidelines aim to clarify medicines category considered to be high-alert status and to outline
the various strategies for safeguarding the use of high-Alert Medications to improve the patient
safety.

 Definition

High-Alert Medications are medicines that have high potential risk to the patient when they are
utilized in error. Although mistakes may or may not be common with these medicines, the
significances of an error are dearly more devastating to patients.

High Alert Medication Category

Based on error reports submitted to the Institute for Safe Medication Practices (ISMP)
Medication Errors Reporting Program, reports of harmful errors in the literature, and input from
practitioners and safety experts, ISMP created and periodically updates a list of potential high-
alert medications.

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This list must be edited by the Medication Safety Officer in the hospital based on the
available medicines and localized medication error reports.

A- High Alert Medications Classes/ Categories List

 adrenergic agonists. IV (e.g.. EPINEPHrine, Norepinephrine. Phenylephrine)

 adrenergic antagonists. IV (e.g., Bisoprolol. Propranolol, Labetalol)
 anesthetic agents, general, inhaled and IV (e.g., Propofol, Ketamine)
 antiarrhythmics, IV (e.g., Lidocaine, Amiodarone, Adenosine)
 antithrombotic agents, (e.g., Warfarin, Heparin. Streptokinase)
 cardioplegic solutions
 chemoiherapeutic agents, parenteral and oral
 dextrose, hypertonic. 20% or greater
 dialysis solutions, peritoneal and hemodialysis
 epidural or intrathecal medications
 Oral Hypoglycemic: (e.g., Glibenclamide, Gliclazide,Metformin Hcl)
 inotropic medications, IV: (e.g., Digoxin, Milrinone, lnamrinone)
 insulin, subcutaneous and IV
 Narcotics/opioids, IV, transdermal and oral (including liquid concentrates, immediate and
sustained release formulations)

B-Specific High Alert Medications List

 Colchicine injection
 Epoprostenol, IV
 Insulin, subcutaneous and IV
 Magnesium Sulfate injection
 Methotrexate, oral, for non-oncologic use
 Oxytocin, IV
 Nitroprusside Sodium for injection
 Potassium Chloride for injection concentrate
 Potassium Phosphates injection
 Promethazine, IV

Managing High Alert Medications

 The pharmacy department in the hospital needs to provide general guidelines for the
proper handling of High Alert Medications including the medication list, in accordance
with the CBAHI Standards
 Concentrated electrolytes (Potassium & Sodium Phosphate, Potassium Chloride, and
Sodium Chloride) are High-Alert Medications, so should not be stocked in the patient
care areas except as part of the crash cart medications, limited quantities of these
concentrated electrolytes can be stocked in specific area such as ICU and ER and need to

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 be keep in a separate locker and away from the regular ward stock medications and
should by monitored frequently by nursing and pharmacy staff
 Label all containers and shelves used for storing High Alert Medications as “HIGH
ALERT MEDICATION”
 High Alert Medications must be double checked before they are prepared. dispensed and
administered to the patients
 The Medication Safety officer in the hospital must be check if the staff commitment to do
the double check before they are prepared, dispensed and administered to the patients.

Strategies to reduce errors involving with High Alert Medication

1. Procurement

 Limit the drug strengths available in the hospital.

 Avoid frequent changes of brand or color and notify the other healthcare staff if
there are changes.
 Inform all relevant personnel regarding in the hospital about the new High Alert
Medications listed.

2. Storage

 Minimize High Alert Medications from clinical areas, where possible.

 High Alert Medication should be stored individually in separate labeled
plastic container.
 Label the shelves or containers used for storing 111gb Alert Medications as
HIGH ALERT MEDICATION”.

3. Prescribing

 Avoid using abbreviations when prescribing High Alert Medications.

 Avoid ordering High Alert Medications verbally accept in case of emergency
orders have to be repeated and verified.
 Prescribe oral liquid medications with the dose specified in milligrams.
 Avoid using trailing zero when prescribing. (e.g. 5.0 mg can be mistaken as 50
mg)
 Reduce the total dose of High Alert Medications in continuous IV drip bags (e.g.,
12,500 Units of Heparin in 250 ml vs. 25,000 Units in 500 ml) to reduce risk.

4. Dispensing / Supply

 All High Alert Medication containers, product packages, vials or ampoules issued
towards/units need to have caution label “HIGH ALERT MEDICA11ON’ except
for parenteral nutrition preparations.
 High Alert Medications to be dispensed to patients should be not have cautioning
label

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  Accuracy check performance must be applied for the High Alert Medications
before dispense the medicines.

5. Counselling

 Educate the patient and, or the patient family member and the required
information such as; the purpose of taken the medicine, how to take the medicine
and the common side effect of using the medicines

6. Administration

 Nurses must double-check all High-Alert medications before give the dose to the
patient. The following particulars shall be independently double checked against
the prescription or medication chart at the bedside by two appropriate persons
before administration

 Patient’s name and patient fill number

 Medication name, strength and dose
 Route and rate (pump setting and line placements when necessary)
 Expiry date

 Ensure trained personnel do administration of intrathecal, cytotoxic drugs,

epidural analgesics and parenteral nutrition.
 Return all unused or remaining specially formulated preparations to the pharmacy
when no longer required.

7. Monitoring

 Closely monitor vital signs, laboratory data, patient’s response before and after
administration of High Alert Medications.
 Keep antidotes and resuscitation equipment’s in wards) units.

Guide on handling look-Alike & Sound-Alike Medications

The patient safety incidents are widely spread because the health services system become more
complex, due to new technologies, medicines and treatments strategies. Currently, thousands of
medications are available in the markets and in the hospitals.

Some of these medicines have similarity in the names or packaging. The evidences show that
Look-alike/sound-alike medicines names and packaging are one of the most common contributed
factors associated with medication errors.

Look Alike Sound Alike (LASA) medications involve medicines that are visually similar in
physical appearance or packaging and names of medications that have spelling similarities and/or
similar phonetics. Appendix 1 shows a list of medication that have a similarity in names. The
pharmacy department in the hospital needs to update the LASA medications list every year.

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  Objectives

This guideline aims to prevent potentially harmful medication errors that may result from
confusing medication names and similar product packaging and to guide the healthcare providers
and institutes to maintain a good to reduce the medication errors.

 Contributing Factors

Several Contributing factors may lead to confusion with LASA medications, these includes

 Illegible handwriting.
 Incomplete knowledge of drug names.
 Newly available products.
 Similar packaging or labeling.
 Similar strengths, dosage forms, frequency of administration.
 Similar clinical use

Strategies to avoid errors with LASA Medications

1. Procurement:

 Minimize the availability of multiple medicines strengths

 Whenever possible, avoid purchase of medicines with similar packaging and appearance.
As new products or packages are introduced, compare them with existing packaging.

2. Storage:

 Use Tall Man lettering to emphasize differences in medications with sound-alike

names.
 Tall Man lettering (or Tallman lettering) is the practice of writing part of a
medicines name in upper case letters to help distinguish sound-alike/look-alike
medications from one another to avoid medication errors.
 Examples of Tall Man lettering are metFORMIN and metoPROLOL
 Using caution red tag notes on shelves, in order to alert the dispenser that a medicine
has look-alike and sound-alike medicines.
 Using techniques such as boldface and differences to reduce the confusion
associated with the use of LASA names on labels in the medicine’s storage containers
and shelves.

3. Prescribing:

 Place LASA medications in locations separate from each other or in non- alphabetical
order. (a) Write legibly, using both the brand and generic names for prescribing
LASA medications.
 Prescription should clearly specify name of medication, dosage form, dose and
complete direction for use.

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  Write the diagnosis or medication’s indication for use. This information helps to
differentiate possible choices in illegible orders.
 In electronic prescribing system, using techniques such as Tall-man lettering,
boldface and color differences to reduce the confusion associated with the use of
LASA names on the computer screens and medication administration records.
 Communicate clearly. Take your time in pronouncing the drug name whenever an
oral order has to be made. Ask that the recipient of the oral communication repeat the
medication name and dose.
 Minimize the use of Verbal and Telephone orders.

4. Dispensing/Supply:

 Identify medicines based on its name and strength and not by its appearance or location.
 Check the purpose of the medication and the dose for the medicines dispensed.
 Read medication prescription and label carefully at all dispensing stages
 Commitment to a final accuracy check by a qualified person, before handing over the
medicine to the patient or the patient’s representative
 Double check should be conducted at any stage during the dispensing and supply process.

5. Administration:

 Read carefully the medication labels each time during the administration process
 Perform the double check to check actual medicine and compare it with the prescription
and label.
 Check the purpose of the medication and the dose prior to administration.

6. Monitoring:

 Monitor new drugs added to the hospital formulary as they are released and provide
guidelines to these new drugs.
 Monitor patients who may have received wrong medications as result of LASA
medication error.

7. Information:

 Update healthcare professionals of changes on the list of LASA and confusing drug
names.
 Provide education on LASA medications to healthcare professionals at orientation and as
part of continuing education.

8. Patient Education:

 Inform patients on changes in medication appearances.

 Educate patients and their caregivers to alert healthcare providers whenever a medication
appears to vary from what is usually taken or administered.
 Encourage patients and their caregivers to learn the names of their medications.

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9. Evaluation

 Evaluate medication errors related to LASA medications.

Sound ALIKE Medications

LOOK ALIKE Medications

[7]

Part-II: Differentiate between poisoning and toxicities with proper explanation

and management.

Definition of poisoning and toxicity

 Poison and poisoning

A poison is a substance capable of producing adverse effects on an individual under appropriate

conditions. The term “substance” is almost always synonymous with “chemical” and includes
drugs, vitamins, pesticides, pollutants, and proteins. Even radiation is a toxic substance. [8]Taking
a substance that is injurious to health or can cause death. Poisoning is still a major hazard to
children, despite child-resistant (and sometimes adult-resistant) packaging and dose-limits per
container are known as poisoning. [9]

 Toxin and toxicity

A toxin is a harmful substance produced within living cells or organisms; synthetic toxicants
created by artificial processes are thus excluded. The term was first used by organic chemist
Ludwig Brieger, derived from the word toxic. The degree to which a substance (a toxin or

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poison) can harm humans or animals. Acute toxicity involves harmful effects in an organism
through a single or short-term exposure. Subchronic toxicity is the ability of a toxic substance to
cause effects for more than one year but less than the lifetime of the exposed organism. Chronic
toxicity is the ability of a substance or mixture of substances to cause harmful effects over an
extended period, usually upon repeated or continuous exposure, sometimes lasting for the entire
life of the exposed organism. [10]

Types of poison and toxin

 Types of poison

1.  Solid Poisons

These poisons do not get absorbed easily into the blood. These should be dissolved in liquid to
get absorbed. For example- Lead, Arsenic, Mercury etc.

2.  Liquid Poisons

These poisons contain both organic and inorganic liquid. Organic liquids are more volatile than
inorganic liquids.

3.  Gaseous Poisons

These poisons are absorbed by inhalation such as carbon dioxide, carbon monoxide.

 Categories of Poisons

1.  Corrosive Poisons

The poisons which cause inflammation on the site of contract are Corrosive Poisons, comprising
of both Strong acids (concentrated Sulphuric acid, Nitric acid and Hydrochloric acid) and
Alkalis.Strong bases: It includes both hydroxide and carbonate, i.e., Sodium hydroxide,
Potassium hydroxide and Ammonium hydroxide etc. Carbonate: Sodium carbonate, Potassium
carbonate etc.

2.  Irritant Poisons

The poisons which cause irritation, pain and excessive vomiting are known as Irritant Poisons,
these poisons are further divided into:

(Inorganic Poisons)These poisons consist of both metallic (lead, arsenic, mercury, antimony,
bismuth, silver, copper, zinc etc.) and non-metallic (zinc chloride, ferrus chloride, phosphate,
sulphate, nitrate, nitrite etc.) compounds.

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(Organic Poisons)It consists of poisons of both vegetable and animal origin.Animal Poisons
consist of Snakes venom, scorpion venom, cantharides etc.Vegetable Poisonsare the huge class
of poisons which contains various plants which are toxic in nature (croton, castor, calotropis,
nuxvomica, abrus, precatoreous, kaner etc.).

(Mechanical Poisons)The poisons which cause irritation, perforation, obstruction in the

gastrointestinal tract, like powder glass, diamond dust, chopped hair etc.

3.  Neurotic Poisons

These poisons affect the different parts of central nervous system such as Cerebral Poisons
(alcohol, opium, barbiturates, and benzodiazepines) are the examples of Ceberal poisons and are
the Central Nervous System depressing agents, Spinal Poison, the most common example and
important example of spinal poison in Strychnine, which is the active constituent that is derived
from the seed of strychnux nuxvomica, Peripheral Poisons, these are the poisons which affects
the peripheral nerves of the brain such as Curare.

4.  Cardiac Poisons

The poisons which affects the cardiac system, for example Digitalis, tobacco etc.

5.  Asphyxiate Poisons

This category of poison which cause asphyxia to the cells or tissues. Asphyxia is a condition of
two sufficient supply of oxygen which results into shelter. The best and common example of
Asphyxiate is Carbon dioxide, Carbon Monoxide. [11]

 Types of toxin

Toxins cause harm to organisms when the toxic compound comes in contact with or is absorbed
by body tissues. These compounds interact with parts of the body. Toxins vary greatly in the
severity of their affect, ranging from minor but acute (bee stings) to almost immediately deadly
(botulinum).

They can be classified according to the location of the body where their effects are most notable:

 Hemotoxins (for example, found in some snakes) destroy red blood cells and cause
general tissue damage.
 Phototoxins (for example, alpha-terthienyl found in marigold plants) cause allergic
reactions in susceptible individuals.
 Necrotoxins (for example, necrotising fasciitis – flesh-eating bacteria) destroy cells they
encounter and cause general tissue damage. South African sand spiders use necrotic
venom.
 Neurotoxins (for example, tetrodotoxin found in pufferfish and some grey side-grilled
sea slugs) affect the nervous system of organisms. Black widow spiders use neurotoxins.
[12]

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  Pathways for poison and toxin

There are four pathways by which poisons enter the body which ultimately create toxicity in
extreme situation-
 Ingestion (Gastrointestinal Tract)
 Inhalation (Lungs)
 Dermal/Topical (Skin)
 Injection (intravenous, intramuscular, intraperitoneal)
Not all pathways are equally effective. The speed with which a poison can act is dependent on
the pathway it takes into the body. The pathways are listed below from fastest to slowest:
Intravenous (into a vein) injection > inhalation > intraperitoneal (into the body) injection >
intramuscular (into the muscle) injection> ingestion > topical (onto the skin) absorption

Mechanism of poisoning and toxicity

 Mechanism of poisoning

Poisons produce either local effects or systemic effects. They act by increasing or decreasing
body functions or secretion e.g heart rate, respiration, pupil size, salivation, lacrimation,
sweating, urination. Poison also causes biochemical change, a cellular change resulting in
physiological change. Certain neurotoxic poison causes damage to neurons e.g lead, ethanol,
nitric oxide, botulinum toxin, tetanus toxin, etc. Most of the poisons are involved in changing the
oxygen pathway and thereby eventually result in respiratory problems as follows:
 Asphyxiant gases (Carbon dioxide, methane, butane, nitrogen) reduces inspiratory oxygen
fraction
 Cyanide, hydrogen sulfide blocks cytochrome enzyme chain reducing tissue oxygen
consumption failing oxidative metabolism.
 Some poisons such as a botulinus toxin, organophosphate, and strychnine cause respiratory
syndrome by respiratory muscle paralysis or spasm. This results in reduced arterial oxygen
tension.
 Opioid, sedative-hypnotic and barbiturate cause respiratory depression by reducing alveolar
oxygen tension and failure of ventilation.
 Carbon monoxide, nitrites, arsine, stibine causes hemolysis. So, the hemoglobin function
reduces.[13]

 Mechanism of toxicity

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Mechanisms of toxicity can be straightforward or very complex. Frequently, there is a difference
among the type of toxicity, the mechanism of toxicity, and the level of effect, related to whether
the adverse effects are due to a single, acute high dose (like an accidental poisoning), or a lower-
dose repeated exposure (from occupational or environmental exposure). Classically, for testing
purposes, an acute, single high dose is given by direct intubation into the stomach of a rodent or
exposure to an atmosphere of a gas or vapour for two to four hours, whichever best resembles the
human exposure. The animals are observed over a two-week period following exposure and then
the major external and internal organs are examined for injury. Repeated-dose testing ranges
from months to years. For rodent species, two years is considered a chronic (lifetime) study
sufficient to evaluate toxicity and carcinogenicity, whereas for non-human primates, two years
would be considered a subchronic (less than lifetime) study to evaluate repeated dose toxicity.
Following exposure a complete examination of all tissues, organs and fluids is conducted to
determine any adverse effects. [14]

Diagnosis of Poisoning and toxicity

22
A combination of history, physical examination, and laboratory studies will help reveal the cause
of most poisonings. Frequently, treatment must begin before all information is available.

History: As a family member or friend of a poisoned person, you can greatly assist the doctor
and provide valuable clues by telling the doctor about these details:

 Everything the person ate or drank recently

 Names of all prescription and over-the-counter medications the person is taking
 Exposure to chemicals at home or at work
 Whether others in the family or at work have been similarly ill or exposed
 Whether the person has any psychiatric history to suggest an intentional ingestion
(suicide attempt)

Testing: Many poisons can be detected in the blood or urine. However, a physician cannot order
"every test in the book" when the diagnosis is unclear. The tests ordered will be based on
information revealed in the history and physical exam.

 A toxicology screen or "tox" screen looks for common drugs of abuse. Most toxicology
screens will detect:

 acetaminophen,
 aspirin,
 marijuana,
 opioids (heroin, codeine),
 benzodiazepines (diazepam [Valium], chlordiazepoxide [Librium]),
 amphetamines (uppers),
 cocaine, and
 alcohol.

 A specific blood test will give serum levels of some drugs, including phenytoin
(Dilantin), theophylline (Theo-Dur, Respbid, Slo-Bid, Theo-24, Theolair, Uniphyl, Slo-
Phyllin), digoxin (Lanoxin), lithium (Lithobid), and acetaminophen.
 Some drugs affect the electrical activity of the heart. An electrocardiogram (ECG) may
reveal toxicity.
 Sometimes a person is unconscious for no obvious reason. A CT scan of the brain will
help tell if there has been a structural change in the brain, such as a stroke.[15]

Treatment of Poisoning and toxicity

 Supportive care
 Activated charcoal for serious oral poisonings
 Occasional use of specific antidotes or dialysis
 Only rare use of gastric emptying

23
Seriously poisoned patients may require assisted ventilation or treatment of cardiovascular
collapse. Patients with impaired consciousness may require continuous monitoring or restraints.
The discussion of treatment for specific poisonings, below and in tables Common Specific
Antidotes , Guidelines for Chelation Therapy , and Symptoms and Treatment of Specific Poisons
, is general and does not include specific complexities and details. Consultation with a poison
control center is recommended for any poisonings except the mildest and most routine.

 Initial stabilization

 Maintain airway, breathing, and circulation

 IV naloxone
 IV dextrose and thiamine
 IV fluids, sometimes vasopressors

Airway, breathing, and circulation must be maintained in patients suspected of a systemic

poisoning. Patients without a pulse or blood pressure require emergency cardiopulmonary
resuscitation . If patients have apnea or compromised airways (eg, foreign material in the
oropharynx, decreased gag reflex), an endotracheal tube should be inserted (see Tracheal
Intubation ). If patients have respiratory depression or hypoxia, supplemental oxygen or
mechanical ventilation should be provided as needed.

IV naloxone (2 mg in adults; 0.1 mg/kg in children; doses as high as 10 mg may be necessary in

some cases) should be tried in patients with apnea or severe respiratory depression while
maintaining airway support. In opioid addicts, naloxone may precipitate withdrawal, but
withdrawal is preferable to severe respiratory depression. If respiratory depression persists
despite use of naloxone, endotracheal intubation and continuous mechanical ventilation are
required. If naloxone relieves respiratory depression, patients are monitored; if respiratory
depression recurs, patients should be treated with another bolus of IV naloxone or endotracheal
intubation and mechanical ventilation. Using a low-dose continuous naloxone infusion to
maintain respiratory drive without precipitating withdrawal has been suggested but in reality can
be very difficult to accomplish.

IV dextrose (50 mL of a 50% solution for adults; 2 to 4 mL/kg of a 25% solution for children)
should be given to patients with altered consciousness or central nervous system (CNS)
depression, unless hypoglycemia has been ruled out by immediate bedside determination of
blood glucose.

Thiamine (100 mg IV) is given with or before glucose to adults with suspected thiamine
deficiency (eg, alcoholics, undernourished patients).

IV fluids are given for hypotension. If fluids are ineffective, invasive hemodynamic monitoring
may be necessary to guide fluid and vasopressor therapy. The first-choice vasopressor for most
poison-induced hypotension is norepinephrine 0.5 to 1 mg/min IV infusion, but treatment should
not be delayed if another vasopressor is more immediately available.

 Topical decontamination

24
Any body surface (including the eyes) exposed to a toxin is flushed with large amounts of water
or saline. Contaminated clothing, including shoes and socks, and jewelry should be removed.
Topical patches and transdermal delivery systems are removed.

 Activated charcoal

Charcoal is usually given, particularly when multiple or unknown substances have been ingested.
Use of charcoal adds little risk (unless patients are at risk of vomiting and aspiration) but has not
been proved to reduce overall morbidity or mortality. When used, charcoal is given as soon as
possible. Activated charcoal adsorbs most toxins because of its molecular configuration and
large surface area. Multiple doses of activated charcoal may be effective for substances that
undergo enterohepatic recirculation (eg, phenobarbital, theophylline) and for sustained-release
preparations. Charcoal may be given at 4- to 6-hour intervals for serious poisoning with such
substances unless bowel sounds are hypoactive. Charcoal is ineffective for caustics, alcohols,
and simple ions (eg, cyanide, iron, other metals, lithium).

 Gastric emptying

Gastric emptying, which used to be well-accepted and seems intuitively beneficial, should not be
routinely done. It does not clearly reduce overall morbidity or mortality and has risks. Gastric
emptying is considered if it can be done within 1 hour of a life-threatening ingestion. However,
many poisonings manifest too late, and whether a poisoning is life threatening is not always
clear. Thus, gastric emptying is seldom indicated and, if a caustic substance has been ingested, is
contraindicated.

If gastric emptying is used, gastric lavage is the preferred method. Gastric lavage may cause
complications such as epistaxis, aspiration, or, rarely, oropharyngeal or esophageal injury. Syrup
of ipecac has unpredictable effects, often causes prolonged vomiting, and may not remove
substantial amounts of poison from the stomach. Syrup of ipecac may be warranted if the
ingested agent is highly toxic and transport time to the emergency department is unusually long,
but this is uncommon in the US.

25
For gastric lavage, tap water is instilled and withdrawn from the stomach via a tube. The largest
tube possible (usually > 36 French for adults or 24 French for children) is used so that tablet
fragments can be retrieved. If patients have altered consciousness or a weak gag reflex, tracheal
intubation should be done before lavage to prevent aspiration. Patients are placed in the left
lateral decubitus position to prevent aspiration, and the tube is inserted orally. Because lavage
sometimes forces substances farther into the gastrointestinal (GI) tract, stomach contents should
be aspirated and a 25-g dose of charcoal should be instilled through the tube immediately after
insertion. Then aliquots (about 3 mL/kg) of tap water are instilled, and the gastric contents are
withdrawn by gravity or syringe. Lavage continues until the withdrawn fluids appear free of the
substance; usually, 500 to 3000 mL of fluid must be instilled. After lavage, a 2nd 25-g dose of
charcoal is instilled.

 Whole-bowel irrigation

This procedure flushes the GI tract and theoretically decreases GI transit time for pills and
tablets. Irrigation has not been proved to reduce morbidity or mortality. Irrigation is indicated for
any of the following:

 Some serious poisonings due to sustained-release preparations or substances that are not
adsorbed by charcoal (eg, heavy metals)
 Drug packets (eg, latex-coated packets of heroin or cocaine ingested by body packers)
 A suspected bezoar

A commercially prepared solution of polyethylene glycol (which is nonabsorbable) and

electrolytes, as sometimes used to cleanse the bowel for colonoscopy, is given at a rate of 1 to 2
L per hour for adults or at 25 to 40 mL/kg/h for children until the rectal effluent is clear; this
process may require many hours or even days. The solution is usually given via a gastric tube,
although some motivated patients can drink these large volumes.

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  Alkaline diuresis

Alkaline diuresis enhances elimination of weak acids (eg, salicylates, phenobarbital). A solution
made by combining 1 L of 5% D/W with three 50-mEq (50-mmol/L) ampules of sodium
bicarbonate and 20 to 40 mEq (20 to 40 mmol/L) of potassium can be given at a rate of 250
mL/h in adults and 2 to 3 mL/kg/h in children. Urine pH is kept at > 8, and potassium must be
repleted. Hypernatremia, alkalemia, and fluid overload may occur but are usually not serious.
However, alkaline diuresis is contraindicated in patients with renal insufficiency.

 Dialysis

Common toxins that may require dialysis or hemoperfusion include

 Ethylene glycol
 Lithium
 Methanol
 Salicylates
 Theophylline

These therapies are less useful if the poison is a large or charged (polar) molecule, has a large
volume of distribution (ie, if it is stored in fatty tissue), or is extensively bound to tissue protein
(as with digoxin, phencyclidine, phenothiazines, or tricyclic antidepressants). The need for
dialysis is usually determined by both laboratory values and clinical status. Methods of dialysis
include hemodialysis, peritoneal dialysis, and lipid dialysis (which removes lipid-soluble
substances from the blood), as well as hemoperfusion (which more rapidly and efficiently clears
specific poisons—see Overview of Renal Replacement Therapy ).

 Specific antidotes

For the most commonly used antidotes, see table Common Specific Antidotes . Chelating drugs
are used for poisoning with heavy metals and occasionally with other drugs (see table Guidelines
for Chelation Therapy ). IV fat emulsions in 10% and 20% concentrations and high-dose insulin
therapy have been used to successfully treat several different cardiac toxins (eg, bupivacaine,
verapamil).

 General supportive measures

When there are no specific treatments, the physician will treat signs and symptoms as needed.

 If the person is agitated or hallucinating, a sedative can be given to calm the person until
the drug wears off.
 A ventilator can be used to breathe for anyone who has stopped breathing from a
poisoning.
 Antiseizure medicines can be used to treat or prevent seizures.

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  Hospital admission

General indications for hospital admission include altered consciousness, persistently abnormal
vital signs, and predicted delayed toxicity. For example, admission is considered if patients have
ingested sustained-release preparations, particularly of drugs with potentially serious effects (eg,
cardiovascular drugs). If there are no other reasons for admission, if indicated laboratory test
results are normal, and if symptoms are gone after patients have been observed for 4 to 6 hours,
most patients can be discharged. However, if ingestion was intentional, patients require a
psychiatric evaluation. [16]

Prevention of Poisoning and toxicity

In the US, widespread use of child-resistant containers with safety caps has greatly reduced the
number of poisoning deaths in children < 5 years. Limiting the amount of over-the-counter
(OTC) analgesics in a single container and eliminating confusing and redundant formulations
reduces the severity of poisonings, particularly with acetaminophen, aspirin, or ibuprofen.

Other preventive measures include

 Clearly labeling household products and prescription drugs

 Storing drugs and toxic substances in cabinets that are locked and inaccessible to children
 Promptly disposing of expired drugs by mixing them in cat litter or some other
nontempting substance and putting them in a trash container that is inaccessible to
children
 Using carbon monoxide detectors
 Refraining from prescribing opioids and using nonopioid treatments whenever possible

Public education measures to encourage storage of substances in their original containers (eg, not
placing insecticides in drink bottles) are important. Use of imprint identifications on solid drugs
helps prevent confusion and errors by patients, pharmacists, and health care practitioners. [17]

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 References
1.https://s3.amazonaws.com/EliteCME_WebSite_2013/f/pdf/ANCCFL02MEI16B.pdf

2. https://www.fda.gov/drugs/information-consumers-and-patients-drugs/working-reduce-
medication-errors

3. https://www.powerpak.com/course/content/118506

4. https://www.ncbi.nlm.nih.gov/books/NBK51906

5. https://www.ashp.org/-/media/assets/policy-

6. https://www.ncbi.nlm.nih.gov/books/NBK519065/

7. https://fadic.net/medication-error-guideline/

8. https://www.britannica.com/science/poison-biochemistry

9.https://www.medicinenet.com/poisoning/definition.htm

10. https://www.medicinenet.com/toxicity/definition.htm

11. https://www.linkedin.com/pulse/toxicology-classification-poisons-navin-kumar-jaggi

12. https://www.sciencelearn.org.nz/resources/364-poisons-and-toxins

13. https://saspublishers.com/media/articles/SAJP_95_155-162_c.pdf

14. https://www.iloencyclopaedia.org/contents/part-iv-66769/toxicology-57951/mechanisms-of-
toxicity

15. https://www.emedicinehealth.com/poisoning/article_em.htm

16. https://www.msdmanuals.com/professional/injuries-poisoning/poisoning/general-principles-
of-poisoning

17. https://www.msdmanuals.com/professional/injuries-poisoning/poisoning/general-principles-
of-poisoning

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