Endocrine Abstracts

Background: Errors made with critical medicines such as desmopressin and hydrocortisone used in the treatment of endocrine conditions in hospitalised patients can undermine patient safety but are largely preventable.

Methods: Retrospective audit of adult patients admitted at the University Hospitals of Leicester NHS Trust between January 2013 and June 2014, prescribed desmopressin for cranial diabetes insipidus (CDI) or other medical conditions using electronic prescribing (ePMA). Safety concerns were recorded on a scoring system according to pre-defined parameters including patient confusion, abnormalities of serum sodium levels, evidence of missed or delayed administration of desmopressin and hydrocortisone.

Results: 15 patients (seven males) with a median (IQR) age of 56 (17–85) years were identified. 31 hospital admissions were recorded with a median length of stay of 5 days (range 1–30). Among eight patients (17 hospital admissions) with CDI, history of confusion was observed in 12 admissions (70%), six admissions (35%) had abnormal admitting serum sodium levels, and 14 admissions (88%) had 39 missed/delayed doses of desmopressin. Common reasons included, medications unavailable (64.9%), no reason mentioned (15.8%), patient declined (7.0%) and nil orally or wrong timing of medication (12.3%). At least one dose of hydrocortisone was missed in 35.7% admissions. In the non-CDI cohort, seven patients had 14 admissions and in 64% admissions there were 18 missed/delayed doses of desmopressin. At least one safety concern was seen at every hospital admission in the CDI patient group.

Conclusion: Errors in critical medications such as desmopressin in prescribing and administration can affect patient safety and cause clinical harm. Increased pharmacovigilance and robust policies supporting medicines management of desmopressin in clinical areas are of paramount importance and will continue to be needed.