Endocrine Abstracts

Arginine vasopressin deficiency (AVPD) is a disorder of the pituitary gland characterised by an inability to produce antidiuretic hormone (ADH), resulting in the production of large volumes of dilute urine. Untreated, patients with AVPD can develop life-threatening dehydration. Desmopressin is a synthetic form of ADH used to treat AVPD and is considered to be a life sustaining medication in this situation. Between 2009 and 2016 NHS England was made aware of four incidents where omission of desmopressin resulted in severe dehydration and death. In February 2016 NHS England issued a patient safety alert asking for all organisations providing NHS -funded care for treatment of AVPD to take action including: (1) identify if omission of desmopressin for the treatment of AVPD has or could occur (2) consider if immediate action needs to be taken locally. In 2018 the Society for Endocrinology published guidelines for the inpatient management of AVPD. At our organisation since 2016 we have done continuous quality improvement work using the ‘Plan-do-study-act’ cycle. We have had automated medication dispensing cabinets available (Omnicell®) since 2014 which allow all wards to have 24-hour access to desmopressin. When desmopressin is dispensed from the cabinet an email alert goes out to all endocrinologists in the hospital with the inpatient’s details and location, so that they are aware of the admission. The same alert goes out to the nurse who accesses the desmopressin stating ‘do not delay administration.’ We are working to create an alert on the inpatient EPR so that when desmopressin is first prescribed the same alert is sent out to the ward nurses. Our work has led to a reduction in medication safety incident (DATIX®) reports relating to desmopressin (4 between 2015 and 2018 but none since 2022). We hope to roll out the same technology for other life sustaining medications.