Update: Looks like they got it working within 5 minutes of me posting this. It’s a nice format. Check it out for yourself here.

My mother has been doing well since here liver transplant earlier this year, but was recently admitted to a local emergency department with some complications. She was immediately transferred to UCSF where her liver transplant team is. I received the call telling me as much late Thursday night. I couldn’t get any information Thursday night and her life was not in danger so I waited until Friday morning to try to get more details on the situation.

I tried calling my mom’s room directly on Friday morning, but no one answered so I called the nurses station and was told I couldn’t speak with her nurse because they don’t take phone calls between 8:00 – 10:00am. I understand that. It’s prime time for medication distribution on the units and they try to minimize interruptions to prevent medication errors. I get it. Makes sense. However, all I needed to know was what was going on, what they’re doing and what I need to do on my end. I didn’t need her nurse to provide me with the information I needed. They ever so politely told me to call back after 10:00am. Needless to say I was irritated.

Fast forward to 10:00am. I got ahold of the nurse only to be told that she couldn’t tell me anything secondary to patient privacy. Hey, I get it, but I am her son and my name is all over her chart, her durable power of attorney, her medical records, her super secret list of people in the know, etc. Heck, I even set up the password for family members to get updates on her condition when she was there for her transplant. The nurse wouldn’t budge.

My mood went from irritated to pissed. I wanted to reach through the phone and slap the nurse upside the head. I’m several hours away, my mom is in the hospital and I can’t find out what’s going on. After handing up I redialed my mom’s room and eventually reached her. She was tired, in quite a bit of pain and loopy from the meds; not the right person to be giving me information over the phone. While my mom is an intelligent woman she’s not the one that should be answering my questions and being interrogated about tests and procedures. Fortunately she was doing better, but ia am still unclear about the nature of the problem.

According to the UCSF Medical Center website they “define quality as”:

• Superior care and outcomes
• Outstanding patient safety
• Excellent service and patient satisfaction

I think they nailed the first two things on their list, but failed miserably with the third. This is one time when doing the right thing took a backseat to meeting regulatory compliance. In other words, the patient wasn’t the primary focus of the care, the rules were.

And before you privacy and safety nuts start foaming at the mouth consider this: I am the primary decision maker for my mom’s medical care for the past several years; her medical records say as much, at no point did I ask them to risk her safety and all they had to do was check their records to know that they can tell me anything.

I’ve given UCSF the benefit of the doubt many times because I love the university and the medical center, but not this time. This time they get an epic fail.

Anyway, the ISMP alert shared several examples of oral overdoses with Lugol’s solution secondary to confusion between drops and mL’s. However, mixed in with all the “typical” errors, was the little gem below. Even though the error is more than a decade old, I can’t help but wonder “what the heck were they thinking!”. By the way, my initial read through had me thinking cursive “OS” (oculus sinister, i.e. LEFT eye). With that said, I wouldn’t have actually dispensed it because nothing else on the prescription fits.

One of the errors reported more than a decade ago involved an order to administer 10 drops of Lugol’s solution mixed with "OJ" (orange juice), but nurses misinterpreted "OJ" as OD (right eye). The patient received several doses of Lugol’s solution in his right eye. The error was identified when the patient complained to the physician about how painful the eye drops were.

I have enjoyed compounding throughout various stages of my career. One of the best jobs I ever had was as a compounding pharmacist at a small community pharmacy in San Jose, California. The job was challenging, fun and centered on patient care. For many years I dreamed of having my own compounding pharmacy, but I was never able to make it a reality for numerous reasons. And because of this I was disheartened to read a recent editorial by Dr. Loyd V. Allen, Jr. writing about the lack of compounding content at the recent ASHP Midyear in New Orleans.

In the editorial Dr. Allen writes:

Having just returned from the 2011 ASHP Clinical Midyear Meeting in New Orleans, promoted as the largest gathering of pharmacists in the world, one wonders what the programming committee considers as important topics.

In a year where the number of drugs in short supply exceeds 250, and profiteering rampant among those greedy companies that can purchase and then resell at up to 4000% profit, one wonders why there was no dedicated programming on compounding of drugs in short supply or criteria involved in selecting a compounding pharmacy for outsourcing, both nonsterile and sterile.

Actually, there appeared to be only about 3 posters related to compounding and only one podium presentation. There were untold numbers of sessions on therapeutics, automation, administration and other topics that are covered in detail every year.

With hospitals implementing USP <797> and many actually outsourcing compounding to those pharmacies that can service them, one wonders what is the reason for the lack of programming related to pharmacy compounding. Is it that many pharmacists have not been trained in compounding and realize its importance? Or, they are so busy with distributive, administrative and clinical duties they don’t have time to worry about the drugs that are required for their patients? After all, without the drugs, there is not much need for pharmacists. Or, is it that many consider the highly technical and scientifically based compounding practice can be done by technicians; some of which are good but they do not have the background necessary for formulation, quality assurance, etc. And none have the knowledge base or the responsibility of final approval that a pharmacist has.

It was a very disappointing meeting from the standpoint of educational sessions. There were a significant number of compounding support companies in the exhibit hall and their presence was quite significant. However, to me it seems that there is a disconnect between ASHP programming and the critical needs of patients for their pharmaceuticals.

The profession, she’s a changin’.

The data were on the physician’s external hard drive, officials said. Though the hard drive was encrypted, a piece of paper with the password was nearby and is also missing. The physician notified UCLA the next day and officials began identifying patients affected.”

I am continuously amazed at the number of security breaches involving patient healthcare information caused by careless use of portable storage media like external hard drives, flash drives, and even laptop hard drives. Patient information should never be stored or transported this way. I believe that utilizing cloud computing with simple browser access is a much better solution. 

What makes this particular incident so bad is the cause; reckless behavior by a physician. This wasn’t UCLA’s fault, per se. Sure, the medical center must accept a share of the responsibility, the lion’s share of the blame falls in the lap of the physician. Not only did the physician have sensitive patient information on an external hard drive, but was dumb enough to have the password to access the drive on a piece of paper next to it. Kind of defeats the purpose of encryption and passwords, doesn’t it.

For an eye-opening look at the magnitude of data loss and security breaches drop by DataLossDB.org sometime. It’s scary stuff.

Many of my followers were kind enough to tell me I’d been hacked prior to unfollowing me. And of course Twitter followed suite several hours later by sending me an email letting me know they’d reset my password and encouraging me to check my settings for suspicious third party apps. It didn’t really matter by then as I had already changed my password a couple of times. The damage had already been done.

I don’t typically believe in violence to resolve a problem, but this is one of those rare occasions where I think violence is the perfect answer. Just me, a locked room with the person who created the hack inside, a blowtorch, some sharp objects and a long rope with a noose at the end. Sounds fair to me.

There are several definitions for the word opinion. The one I like comes from Merriam-Webster and reads “belief stronger than impression and less strong than positive knowledge”. Opinions are beliefs; something you think. They are not rooted in fact – although facts can play a roll in forming an opinion – nor are they required to be acknowledged by anyone other than the one giving the opinion. You have your opinion and I have mine. What if they’re different? No matter because they’re opinions.

Where we get ourselves in trouble is when we start thinking of one’s opinion as fact, or something close enough to fact that is must be acted upon. I frequently see this when someone with “expert” stamped on the end of their name says something like “you should …” or “why don’t you …”. Instead of evaluating statements like these and thinking them through many people will simply accept  them as fact and act on them. This is a bad thing. Why? Because everyone has an opinion and they don’t often line up with each other. This is especially true in healthcare; pharmacy in particular.

We have a habit of taking an idea, passing it around the table, collecting opinions and making every attempt to act on them all. I see this a lot with automation and technology. Hey, I’m all about functionality, but not at the expense of common sense. When you try to incorporate everyone’s opinion into a product you get the object to the right. I’m sure someone thought this was a good idea; someone must have requested all that functionality, right? Sure. It’s the most functional piece of utility equipment in the history of mankind, but practical it is not. Try putting it in your pocket. This is what many pieces of pharmacy automation and technology turn into once everyone’s opinion is taken into account.

This goes doubly when people start suggesting that something needs to be added secondary to safety; “that should be added because it’s a safety issue”. Ah, the battle cry of those that know their opinion can’t stand up to close scrutiny. I get this one all the time. I suppose walking around in a suite of chainmail armor and driving 25MPH on the freeway would be safer than the way we do things now, but I just don’t see that happening anytime soon. It’s just not practical. And at the most basic level we give up the marginal difference in safety for the efficiency and practicality of wearing jeans and t-shirts while driving 70MPH. It’s a matter of compromise between form, function and usability combined with taking a little responsibility for our actions.

You simply can’t replace human responsibility and accountability with automation and technology. We need people to be responsible for their actions. It’s the only thing that keeps us honest. Without it everyone’s life will be like Phil Connor’s (Bill Murray) in Groundhog Day before he figured it all out.

Ask a nurse how much time they spend documenting and double documenting things to meet some arbitrary rule or regulation. You’ll be surprised by the answer. Now ask a pharmacist or a physician. You’ll get the same ugly responses. I know a lot of my time as a clinician was spent generating documentation to cover my ass rather than helping care for a patient.

Unfortunately the need to comply with government agencies and silly rules inside the walls of healthcare has generated an unwanted side effect – lack of innovation. Why? Because all that innovative energy is spent on regulatory compliance instead of other, more useful things.

I’ve been involved in several conversations over the last month dealing with how to best use pharmacy automation and technology to increase efficiency and solve problems. Would you like to venture a guess as to what most of those conversations centered on? Yep, how to automate some documentation process or create technology to meet some new regulatory compliance. None of the discussions have been about providing better, safer, more complete patient care.

If you don’t think this is a major problem, think again. I was reading a blog by John Halamka last night in which he discusses the ‘Burden of Compliance’. In the blog John states that “[a]s we draft new regulations that impact healthcare IT organizations, we need to keep in mind that every regulation has a cost in dollars, time, and complexity.” Just remember, there is a finite amount of dollars and time floating around in healthcare these days. If a majority of those dollars and time are gobbled up by regulatory compliance, what does that leave for innovation to actually improve medication distribution, safe administration and better patient care? Precious little if you ask me.

I was searching for something completely unrelated to forklifts when I came across the video below. I was both horrified and amused.

I would be left out in such a world. You see, I don’t have a residency of any kind under my belt. Lots of experience, but no residency. I’ve precepted pharmacy residents, some brilliant and some as dense as rocks. Their abilities to perform at a high level had more to do with their intelligence and common sense than their education. While I like to tease other pharmacists about their alumni status, I’ve found that true skill rarely cares what pharmacy school you went to.

One of the problems I see with the call for residency is a loss of pharmacy identity. Many pharmacists want to practice at the patient bedside. I think that’s a good idea. However, I believe we should be practicing pharmacy at the bedside. We’re drug experts. We know things about medications that few other professions know because we’re supposed to. Any monkey can pick out a drug to treat a disease state. It’s things that occasionally happen after that that requires specialized drug knowledge. Pharmacists are experts not only in the obvious, but the subtleties as well. Who else but a pharmacist would care about the structure activity relationship of a drug or its acid-base properties? Probably no one. While these things rarely matter in the routine care of a patient, when they do it makes a difference. Pharmacists are taught to think about the drug first, and last; everything about the drug. We’re the only profession that does that.

I agree that pharmacists have lots to offer to patient care, and I also believe that pharmacists shouldn’t be tied to the physical pharmacy. With that said, don’t let the fact that pharmacists are drug experts escape you. I fear that the push for residency and specialized residencies will drive pharmacists away from the very thing that makes them unique into a world already inhabited by plenty of would-be practitioners. Be careful what you wish for pharmacists, you just might get it.