The problem is more widespread than most realize and often flies under the radar. I knew about the issues, but wasn’t prepared to deal with them until we went live with our bar-code medication administration (BCMA) system. A side effect of the BCMA system is that it tends to catch things like late and/or early medication administration. That means no more mythical med passes with all medications administered at exactly the same time.

One thing to remember here is that the problem does not reside with the nurses, per se. There are many factors involved. Nurses are frequently asked to do too much with too little time and resources, thus forcing them into undesirable situations. The system is the problem. And as much as it pains me to say, this is one problem where a technology-only solution is not the answer.

The solutions are simple, but not always obvious or practical for many health care facilities. For example, the 30-minute rule could be changed to a 60-minute rule, i.e. medications would need to be administered within 60 minutes before or after their schedule administration time. This was recently done by the American Association for Respiratory Care (AARC) in a position statement that basically said that inhaled medications shouldn’t be held to the same CMS 30-minute rule because “Inhaled medication administration incorporates a unique methodology and has a recognized delivery time between 9-20 minutes, depending on the delivery device used for administration.” The AARC statement is supported by CMS. Or perhaps the facility could stagger standardized frequencies to give nurses additional time to admister medications, i.e. not have all morning medications due at 9:00 am. It may be as simple as moving some medications like aspirin, warfarin or HMG-CoA reductase inhibitors, i.e. atorastatin  and the like to the evening time. How about this one: hire more nurses. I know, easier said than done, but very practical nonetheless. It’s important to remember that this is first and foremost about safe and effective patient care.

Ultimately there isn’t a one size fits all approach to the problem and it is clear that it will be some time before we have a solution, but it is certainly something that needs to be addressed. Unfortunately this isn’t a problem that immediately available technology can fix. ADCs are not designed to be a time saver for nursing. Neither are Bar-code Point of Care (BPOC), a.k.a. BCMA, systems or Computerized Provider Order Entry (CPOE). All these technologies are designed with the idea of improving patient safety through the reduction of hospital related medication errors. We’re going to have to look somewhere else for a solution. Just a thought.

The concept is simple and goes something like this:

1) Place labels containing the drug name and associated bar-code on the pockets of your code boxes, anesthesia trays, transport boxes, etc.

2) Pull items that need to be placed in these trays/boxes from pharmacy stock.

3) Scan the bar-code on the pocket followed by the bar-code on the medication. If the bar-codes match you get a stamp of approval and proceed to enter the lot number and expiration information found on the medication for tracking. If the bar-codes don’t match the software gives you a rude warning in the form of a visual queue that says “No Match!” in big red letters. In addition to the “No Match!” warning, a pop-up window appears that prevents the user from continuing.

Pretty simple, but effective if used properly.

In addition to the safety features offered by RxVerify, the system offers various reports for tracking and record keeping purposes. The ability to track lot number and expiration dates is a big plus.  One of the reports that is of particular interest to me is the “Med Error Prevention Report”. This report identifies what I like to call “bad scans”. Basically it tracks potential errors caught by the system. Of course not all the bad scans would result in a drug error, but the information can be useful nonetheless.

You can watch a video overview of RxVerify here. The video contains information on more than one product, but the the section specific to RxVerify begins at around the 12 minutes mark and runs through about 18:45.

Simple, yet cool.

From the RxVerify website:

RxVerify© (Prevent pharmacy restocking errors with a proven and effective control measure: The medication barcode!)

RxVerify© is software which uses the medication barcode to ensure quality assurance for the restocking process. The medication barcode is a proven and effective control measure for preventing medication restocking errors. This software is commonly used by pharmacy technicians for accurately restocking the following medication storage location types:

Anesthesia/surgery Medication Trays
Code Cart Med Trays
Emergency Med Boxes
Med Transport Kits
Surgery Med Carts
Any medication storage kit/box

RxVerify© not only provides quality assurance for medication selection, but it also prevents medications which are expired or nearly expired from being used for restocking.

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iPhone version

Created with consumers in mind, the iPhone application delivers information about OTC products using the barcode located on the medication package. Users simply type in the numbers on the barcode and receive a picture of the medication along with important drug facts.

By simply touching the picture of the medication, a screen will appear where users can view the medicine’s active ingredients, warning, dosage information, and comparable generic products.

To compare multiple medications users can touch “Check Interaction” located on the main screen. A green check means the OTC medications are ok to take at the same time; a red stop sign means you should not take the medications together and consult with a pharmacist.

Android OS version

The Medilyzer Android Application is very intuitive and easily navigated. To enter anOTC medication, simply touch the “Scan Medication” button. This button activates the camera and the barcode is captured using an easy point and shoot method.

When the product barcode correctly appears in the window, the phone will blink green then display the name of the scanned medication. Users can view information such as product warnings and comparable generic products.

To check OTC drug interactions simply touch “Scan Medication” once more to learn if two OTC can be taken at the same time.

I find it interesting that you can scan the bar code image on the Android version of the software, but have to manually enter the UPC code on the iPhone. I wonder if it has anything to do with the quality of the cameras on the devices or if it is an issue with actual operating system? Anyway, I loaded both my DROID and iPhone with Medilyzer and took it for a test run.

The Android version had difficulty scanning bar codes on any surface other than the flat side of a box. In other words I couldn’t get it to scan bar codes on bottles. When it did pick up the bar code image the software worked as advertised. On the iPhone everything went smoothly. The only issue I have with the iPhone version is the need to manually enter the UPC.

In theory Medilyzer is a great application and has tremendous potential for consumer safety, but I can’t recommend it for Android devices because of the extreme difficulty I had getting a clean scan off surfaces that weren’t completely smooth and flat. The iPhone version works fine if you don’t mind entering the UPC code by hand.

The Waltham, Mass.-based IntrinsiQ’s IntelliDose calculates and tracks the administration of chemotherapy treatments and will enable Allscripts’ multi-specialty and oncology clients to manage oncology patient care workflow, according to the company.

Under the agreement, oncology practices will work with Allscripts account managers to coordinate with implementation and training specialists from the IntelliDose team. Integration of IntelliDose into Allscripts tools will enable Allscripts clients to select the add-on program to navigate patient records across both systems, IntrinsiQ stated. “

This sounds like an interesting concept. I tried looking for detailed information on IntelliDose, but really couldn’t find much. Based on information at the IntrinsiQ website it appears that IntelliDose is a clinical decision support system designed specifically for chemotherapy. Based on the description, IntelliDose does many of the same things that a pharmacy information system does, i.e. checks for “body surface area limitations, patient allergies, and exceptional lab results” in addition to reviewing “dosage variables such as ideal weight, serum creatinine, and creatinine clearance.” Sounds like a pharmacist.

Like many facilities, my hospital is in the process of gearing up for CPOE. We’re in the initial stages where committees are being formed, money is being spent, groups are gathering to discuss who is going to do what and IT, pharmacy and nursing are busy trying to figure out how much impact CPOE will have on their departments. Make no mistake, regardless of the impact, we’re moving forward.

The reasons for implementing CPOE are clear: it has the potential to eliminate illegible orders, eliminate the use of error prone abbreviations, create fewer phone calls from the pharmacy, decrease the number or incomplete orders written by providers, increase formulary compliance, improve provider compliance with hospital guidelines and with the right clinical decision support system can potentially decrease dosing errors, adverse drug events and potential patient harm. (Arch Intern Med 2003; 163: 1409-16 , JAMA 2001;285:2114-2120, JAMA 1998;280:1311-1316, Pediatrics 2009;123;1184-1190, Pediatrics 2010 May 3 [ePub]). However there is enough literature out there to at least question everything I just said (Pediatrics 2005;116:1506-1512, Pediatrics 2006;118:290-295, JAMA 2005;293:1197-1203), but overall I see the benefits of using such a system. There’s a decent summary of CPOE literature in Ann Intern Med. 2003;139:31-39. The information is a bit dated, but it’s a good place to start. Another good reference area is the CPOE page at AHRQ.

In addition to the benefits listed above CPOE has a tremendous upside for pharmacists. CPOE has been shown to potentially reduce pharmacy order-processing time, which in theory frees up pharmacists to concentrate on patient care (Am J Health-Syst Pharm 2009;66: 1394-1398). And we all know that pharmacists at the bedside can reduce medication errors and save money (Am J Health-Syst Pharm 1997;54:1591-1595, Pharmacotherapy 2008:28:285e–323e, JAMA 1999;282:267-270). This is one thing that BCMA hasn’t been able to do for us. We’ve seen benefits from bar coding in terms of inventory control and safety, but the workload in the pharmacy has increased since implementation. However, there are several things that can be done to alleviate the additional workload, including tech-check-tech and re-engineering our workflow, but at this time we haven’t put a lot of effort into improving the situation.

With all that said, CPOE implementation is a daunting task. It’s time consuming and it’s difficult. There is no question that CPOE implementation will require significantly more financial and labor resources than BCMA implementation did. The financial impact alone is enough to give many health care systems pause. I’ve seen numbers in excess of 10 million dollars for CPOE; in comparison we spent less than 1 million on our BCMA implementation, slightly more if you include the pharmacy automation. Still, it is obvious to me that CPOE is a worthwhile endeavor and cost of implementation shouldn’t be the only factor that deters your facility from moving forward. The potential to improve the quality of patient care, save some lives and get pharmacists out of the pharmacy and up on the nursing units is enough to convince me.

I’ve been fortunate in recent weeks to sit in on some of the CPOE decision making meetings, and some of the things that have been identified as necessary for our success include:

Ownership/Governance
The end users must control the design and implementation of our CPOE system. And the end users are primarily the physicians and secondarily the nurses and unit secretaries. Therefore the process must be driven by physicians. A healthcare system can build the best CPOE system in the world, but if the physicians hate it there is little hope for success. The need to engage the end user isn’t unique to CPOE, and should be applied to all technology projects. For example, the need to engage nursing early and often during BCMA implementation.

Following implementation physicians must take ownership of the CPOE system to continuously improve and optimize its look, feel and functionality. Allowing physicians to lose interest will result in a slow, agonizing CPOE death. Don’t think it can’t happen as there is precedent for uninstalling a CPOE system following implementation; <cough> Cedars-Sinai. To prevent physicians from becoming frustrated with the system or from feeling that their opinions don’t count, identify several physician champions to drive the process. Keep the mind set positive.

Understanding that physicians must take ownership of CPOE, hospital administration must provide a strong leadership infrastructure to deal with issues that are bound to come up.

The order set dilemma
Order sets are both loved and hated by pharmacists. On the positive side they hold the key to complete, legible and logical orders. On the negative side they can increase workload for the pharmacy and be just as incomplete, illegible and illogical as their pen and paper counterpart. Make sure to review all current order sets and physician templates prior to starting your CPOE build.

We started the process of critically evaluating every pre-printed order form that comes through the pharmacy. Let me just say it’s been interesting.

All orders on each order set must be complete from start to finish: drug, dose, route, frequency, indication in addition to criteria for use when multiple drugs are used for the same prn indication, i.e. mild pain, moderate pain, severe pain, etc. It’s important to remember that physicians are not experienced with order entry, so what makes sense to you as a pharmacist might not make sense to them. Oh, and make sure all your order sets have a similar look and feel. This gives the physicians some familiarity in which to work.

Building order sets and having them make sense is a real hassle so consider using something like ZynxOrder to help ease the pain. I recommended using ZynxOrder to manage our order sets, but unfortunately the system is expensive and our leadership decided to go in a different direction. The ZynxOrder system is designed to help build evidence based order sets supported by current literature. In addition it offers version control and an upload tool for moving order sets from the development environment into our pharmacy system, i.e. Siemens. Maybe next year.

Design protocols for use across multiple order sets. By this I mean develop standardized order set components for pain, bowel care, DVT prophylaxis, GI prophylaxis, etc. At the same time make sure to remove all range orders like morphine 1-10mg IV every 2-4 hours prn severe pain. The double range makes no sense. In fact the use of a range in frequency makes no sense.

Make order sets that are applicable across a discipline, not physician specific, i.e. there should be only one order set for routine postpartum care not a different order set for each OB-GYN physician. You’ll have a fight on your hands over this one, but stay strong because the end result is worth it.

Clinical decision support (CDS)
Invest heavily in clinical decision support (CDS). In order to take advantage of all that CPOE has to offer you absolutely have to use a robust clinical decision support system. Without CDS all you have is a glorified word processor. One word of caution, be careful not to expose the physicians to too many alerts. There’s a fine line between helpful and annoying. Most alerts in the pharmacy system are annoying. Physicians won’t put up with it. An article published in the Archives of Internal Medicine (Arch Intern Med 2003;163:2625-2631) showed that physicians overrode 91.2% of drug allergy and 89.4% of high-severity drug interaction alerts with no statistically significant change in ADEs. So make sure pop-up alerts and warnings are appropriate.

Support, training and hardware
Make sure your IT department is ready for a lot of hand holding. We did this with BCMA and it seemed to work well. And for the love of Pete, make sure your hardware is plentiful and up to date. One of the most annoying things in the world is logging into one of the computers in the hospital only to have it go up in flames when you’re in the middle of something. Murphy’s law tells us that this will always happen when you’re in the middle of the biggest order of the day and you don’t have a moment to spare. This goes for wireless connectivity as well. Moving into a patients room with a COW only to find that you have no Wi-Fi can really put a wrinkle in your day.

Conclusion
That’s it. I’m knee deep in CPOE stuff at the moment and don’t think I’ll be coming up for air anytime soon. At least things will be interesting for a while.

Here’s an HL7 feed from a ketorolac order. Note the red lettering:

PID|||0000194291^9^M10^KDHCD^PN~3017197^^^KDHCD^MR|3017197|ZZZTESTINGDRAEGRXXXX, ZZZTESTING||19740525|F|||361 N ABC AVE^^VISALIA^CA^93291|||||S|UNK|00001942919|||
PV1||I|3N^29^A||||TEST, A DOCTOR|||OP|||||||TEST, A DOCTOR |||||||||||||||||||||||||||200810231335||||||
ORC|NW|1|||||^Q6H&0600,1200,1800,2400&^^201004292400^201004302400^^^11111110||201004281226||JFT|TEST, A DOCTOR|||201004290000||
RXE||543^KETOROLAC TROMETHAMINE^2502190|30||MG|VIAL|THIS IS ONLY A TEST…..|||1|||AM1405427|JFT|||||||||||
NTE|||EVERY 6 HOURS|RXR|IV||||

Pyxis doesn’t recognize 2400 as a “real” time, and rightfully so. For those of you that don’t know, 2400 hours doesn’t exist in military time. Midnight is 0000 hours. Why would Siemens use 2400 hours to represent midnight? I have no idea, but Pyxis didn’t like it so it refused to deal with the order and simply discontinued it. The fix was a programmatic change by Siemens.

The idea of standardization isn’t new or limited, yet its use continues to elude healthcare. The concept is applicable to not only data, but processes as well. Unfortunately not everyone buys into the idea. I’ve even heard some argue that standardization removes clinical decision making from healthcare. What? That doesn’t even make sense. Standardized processes can actual create clinical decision making time by simplifying a repetitive task and creating consistency designed to prevent errors.

I spent several wonderful years working in a compounding pharmacy in the Bay Area; 3 years as an intern and about 2 years as a pharmacist. Many extemporaneous compounding formulas are complex so the owner of the pharmacy, whom I had tremendous respect for, had a rule that ingredients were placed to the left of a compound prior to use and to the right after use. If you’ve ever worked in a busy pharmacy then you understand interruptions and how easy it is to forget something in a hectic environment. The rule was a simple one, but saved my bacon on more than one occasion. And it certainly didn’t impair my clinical judgment. Similar standardized systems are used in hospital cleanrooms where attention to ingredient detail is paramount.

Other standardized processes that I’ve found beneficial over the years include:

• Standardized doses for pediatrics. I spent a few years working in a pediatric ICU. The facility I worked for had a robust set of policies that allowed the pharmacist to round doses ordered in mg/kg to the nearest “standardized dose”. For example let’s say a physician orders metoclopramide 0.15 mg/kg in a 1.85kg child. The resulting dose is approximately 0.28mg. As a pharmacist I was allowed to round that dose to 0.3mg, which was an available standardized dose. The advantages were obvious: fewer dosage sizes meant less waste, less labor for preparation and fewer opportunities for error, i.e. grabbing the wrong dose. In addition, many of the dosing increments requested were too small to be accurately measured by a syringe and would have been an estimate anyway.
• Standardized drip concentrations. Many hospitals use standard drip concentrations for pressors and other vasoactive medications, i.e. dopamine, norepinephrine, dobutamine, etc. This makes order entry easier and faster, reduces waste, reduces the risk of programming errors on pumps and creates a less complex process for drug dictionary maintenance on smart pumps.
• Standardized administration times. I love the use of standardized administration times. What’s a standardized administration time? I’m glad you asked. That’s when a hospital defines the times a drug will be administered based on the latin sig used, i.e. Q6H may be represented by 0000, 0600, 1200, 1800 or TID may be 0700, 1300, 1800. There are many possibilities. The use of standardized administration times has many advantages including easier and quicker order entry, consistency among nursing staff and less variability for the patient. Those that argue that this is a bad idea because it is difficult to get on a standardized schedule, just give me a call. There is absolutely no pharmacokinetic or pharmacodynamic reason why medications cannot be administered on a standardized schedule while in an acute care setting. You can try to argue that you can’t wait an extra 12 hours to give a multi-vitamin or that you can’t give cefazolin 2 hours early, but you won’t win based on any science that I’ve studied.

One thing to remember when creating a standardized process is to keep it simple. We often forget that complicated processes are fraught with opportunity for error. Everything we do should be broken down into the fewest possible steps and still remain safe and effective. Personal experience tells me that we’ve done a poor job of simplification in healthcare. We tend to complicate a process more often than simplify it; double and triple checks with multiple initials, paper trails, sign-off sheets, pharmacokinetic tracking forms, SBAR forms, manual lot number tracking, etc. If you’re using a paper form in this age of technology, you’re doing something wrong.

Don’t feel bad, we’re not the only ones responsible for creating a bloated and oftentimes overly complex system. Every time something goes wrong in healthcare the federal, state and local governments enact new regulatory processes that requires a barrage of paperwork and complex procedures. It’s an all-out assault on simplification, standardization and common sense.

Have you ever wondered why it takes so long to train a pharmacist after they’ve been hired? Every pharmacist has a similar core skillset that can be applied to most situations, right? Right. Their lengthy on the job training has nothing to do with their drug knowledge or decision making skills, but everything to do with learning all the idiosyncrasies associated with practicing pharmacy in an acute care setting. They have to spend time learning the rules, then the exceptions to the rules, then the exceptions to the exceptions and so on down the line. I’ve worked in six different hospitals during my benign career, so believe me when I tell you that it’s true. Some of the systems I’ve been exposed to were so old and complex that no one could remember when they were implemented, but everyone was afraid to change them.

It has been a busy month, so I won’t make any promises, but over the next couple of weeks I hope to present a couple of additional examples of where standardization is needed in pharmacy and why it’s necessary. Stay tuned.

Feel free to comment on what you think is wrong with this paragraph. Don’t look too hard because it should be immediately obvious to all healthcare providers. I’ll update the post tomorrow.

One thing I found amusing in the article was figure 1 on page 1706 (bottom image). I’ve had a similar visual on one of my office whiteboards (top image) for nearly a year. I like being on the same page with intelligent people.

I’ve been a pharmacist for more than 10 years now and I’ve make my fair share of mistakes. I would like to think that none of those errors caused harm, but that would be naïve to say the least. And forget about the errors that were never detected because one can only speculate about those.

During my early years of staffing I entered anywhere from 300-400 orders per shift; more with overtime, extremely busy days, etc. Assuming that I was 99.9% accurate, which is a ridiculous assumption, let’s do a little math.

- 300 orders per shift x 4 shifts/wk x 50 weeks/year (hey, everyone gets a vacation) = 60,000 orders entered annually

- With 99.9% accuracy, don’t laugh, that means I committed approximately 60 errors per year. Now I know that accuracy rate is a crazy estimate. I’d believe 60 errors per week, but 60 errors per year, c’mon.

- Anyway, assume 60 errors annually for 10 years = 600 medication errors that reached a patient

- Based on numbers from various sources I’m going to assume that a majority of these errors were harmless. Using similar sources I’m also going to assume that approximately 3% of my errors inflicted damage in one form or another. That means I managed to harm approximately 18 patients during a ten year span in my career. How many of those 18 patients were seriously harmed or even killed secondary to one of those mistakes? We’ll never know.

For those pharmacists that think they don’t make mistakes, think again. There is zero chance that you won’t harm a patient during your career. If you’re fortunate you’ll never know. If you’re unfortunate you have the potential to be fired, lose your license, or end up in prison like Eric Cropp. So much for just culture.

We don’t mean to make mistakes. No one rolls out of bed and says “hey, today it’s my turn to make an error”. By definition an error is unintentional (from Merriam-Webster an error is “an act involving an unintentional deviation from … accuracy“) and everyone makes them. So how do we eliminate them? We can’t because they’re unintentional or weren’t you listening. As long as humans are involved in the process there will be mistakes. And I don’t believe that you can remove humans from the practice of pharmacy because in certain circumstances you need insight and experience that no amount of automation can emulate, yet.

We can, however find ways to reduce errors. I firmly believe that technologies like CPOE, BCMA, CDS, robotics, or some yet to be developed system will prove beneficial in reducing medication related errors, but they will never completely eliminate them. I also believe that diligence and exploration into ways to incorporate new dispensing techniques, better practice models, evidence based practice and workflow modeling can help reduce pharmacy related errors as well. It’s silly to think that technology is the only solution.

There you have it; something I neither wished for nor desire to keep, but remains nonetheless. Just a thought.

I recently heard of a case where a hospitals ED system wasn’t interfaced with the rest of the facilities information systems and disastrous results ensued. A patient came in through the ED with a very specific allergy; noted in the ED system. The information wasn’t available in the nursing or pharmacy systems. The patient was admitted and transferred to the floor. The little detail about the allergy wasn’t passed on during report and the patient ended up receiving that very medication based on the attending physician’s order. To make a long story short, the patient had an anaphylactic reaction and won a three day, all expenses paid trip to the hospitals intensive care unit.

I wonder how often things like this happen due to short sided HIS implementation and deployment. Technology might not be the answer to all our problems in healthcare, but you have to admit it certainly could have helped in this particular example.