Baffled by Botulinum ToxinA 5-year-old boy with transverse myelitis presented to the rehabilitation medicine clinic for scheduled quarterly botulinum toxin injections to his legs for treatment of spasticity. Halfway through the course of injections, the patient's mother noted her son was tolerating the procedure "much better than 3 weeks earlier"—the patient had been getting extra injections without the physicians' knowledge. Physicians discussed the risks of too-frequent injections with the family. Fortunately, the patient had no adverse effects from the additional injections. Krishnan Padmakumari Sivaraman Nair, DM, of Royal Hallamshire Hospital in Sheffield, England, describes risks related to the increasing use of botulinum neurotoxins by different specialists for varying indications, and advocates for improving communication between specialists to avoid errors.
Baffled by Botulinum Toxin
Commentary by Krishnan Padmakumari Sivaraman Nair, DM
A 5-year-old boy with a history of transverse myelitis with resultant spasticity of both lower extremities, gait abnormalities, neurogenic bladder, and neurogenic bowel presented to the rehabilitation medicine clinic for scheduled botulinum toxin (Botox) injections to his legs. He had been receiving Botox injections approximately every 3 months to his bilateral hamstrings, hip adductors, and gastrocnemius. Due to the patient's age and parent preference, he was given a dose of midazolam for sedation in the office prior to his injections.
The attending physician, fellow, and nurse went in the room to perform the injections. A time out was completed and the patient information, procedure, and sites were verified. About halfway through the 12 injections (2 to each muscle group on each side), the patient's mother said, "Wow, he is responding much better to the injections and sedating medications this time than he did 3 weeks ago." The attending and fellow were confused, as it had been 3 months since his last injections in the rehabilitation medicine clinic. Upon further questioning, the mother clarified that the clinicians in the urology clinic had had Botox injected 3 weeks earlier for management of the patient's neurogenic bladder. The scheduled injections were completed, followed by a long discussion held with the mother about the risk of antibody formation and decreased efficacy from too-frequent injections.
Despite the concerns, the patient had no adverse effects and experienced good results from the injections. However, after the procedure, the attending and fellow reviewed the electronic medical record (EMR) in an effort to understand how this error occurred. They realized that many specialties have begun to use Botox, and each one documented its use differently in the EMR. Whereas the rehabilitation medicine clinic entered a formal procedure note for each treatment, the urology clinic simply documented its injections in progress notes. Procedure notes appeared in a different area of the EMR and were not readily visible to clinicians accustomed to reviewing progress notes or test results.
Based on this review, clinic intake procedures were changed so that nurses now always ask about prior or recent Botox injections. In addition, the hospital's IT department created a clinical alert within the EMR that clearly states when the last order of Botox was given when a provider attempts to order Botox.
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