I’ve attended the last two unSUMMITs; Atlanta in 2010 and Louisville in 2011. The conference is focused on barcoding at the point of care. While it’s not as big as the ASHP conferences, it’s full of people that want to learn about barcoding and patient safety. I found it valuable.

Anyway, I received an email yesterday calling for speakers. I presented at the unSUMMIT last year and found it to be quite rewarding. The 50 minutes I spent on stage opened the door for a lot of post presentation discussion with colleagues. If you’ve gone through barcoding implementation at your facility, or are thinking about it, I would encourage you to not only attend the unSUMMIT, but consider presenting as well. It’s only through sharing information that we get better.

Hope to see you there.

mobihealthnews

“This is the best performing barcode scanner for developers who are creating applications incorporating barcode scanning for the Apple iOS,” stated Samantha Chu, data collection product manager at Socket Mobile, in a press release. “There are numerous applications that stand to benefit from barcode scanning in a range of vertical markets, and we believe the CHS 7Xi provides the Apple developer community with a level of control and data integrity that didn’t exist previously.”

I’ve mentioned the CHS Series 7 scanners before. They really are neat little devices; small, quick and accurate.

Another scanner worth mentioning in this category is the Koamtac KDC200. I’ve used the KDC200 and it’s a pretty slick scanner as well.

I avoided the more traditional sessions on therapeutics, choosing instead to focus on the informatics and medication safety sessions. Based on the information presented it was obvious to me that these two disciplines are intimately linked. After all, the idea behind much of the technology we use in healthcare today is to improve patient safety.

In 1999, the Institute of Medicine (IOM) published the now infamous To Err Is Human: Building a Safer Health System. The information presented in that report sent shockwaves through the healthcare industry. More than a decade later we haven’t seen much improvement in the number of mistakes made in hospitals, but To Err Is Human effectively changed the foundation of healthcare forever. While healthcare remains squarely focused on caring for patients, the approach to how we provide that care has changed dramatically. The interest on patient safety has generated an immense body of literature aimed at using automation and technology to improve patient care.

Before diving too deep, it’s important to understand where the errors within the healthcare system occur. Leape’s landmark paper in 1995(1) analyzing ADEs in hospitalized patients found that adverse events occurred as follows: ordering 38%, transcription 12%, dispensing 11%, and administration 39%. Bates found similar results in a study also published in 1995 in the same issue of JAMA (2). Bates found that of ADEs that were considered preventable, 49% occurred during the ordering stage, 11% occurred during the transcription stage, 14% occurred during the dispensing stage and 26% occurred during the administration stage.

Since the publications by Leape and Bates much work has gone into making the medication use process safer. At the forefront of this work has been an advance in automation and technology. Among those technologies being explored include: 1) computerized provider order entry (CPOE) for ordering; 2) pharmacy information systems and clinical decision support for transcription; 3) automated carousels, barcoding and automated dispensing cabinets for dispensing; and 4) barcode medication administration (BCMA) and smart pumps for administration. This isn’t an all-inclusive list, but rather an example to demonstrate the extent to which healthcare has gone to improve patient safety through the use of automation and technology.

With that said, I find it interesting that one of the most error prone steps in the medication distribution phase is often overlooked. I’m speaking specifically about the process of returning/restocking medications in the pharmacy. I have observed the process many times and outside the use of robotics, the system is completely manual, open to selection bias, full of interruption and fraught with error.

Example return/restocking process:

1. A series of medication are returned to the pharmacy.
2. The medications are placed in a return bin regardless of medication type, dosage form, storage requirements, etc.
3. Tablets in the return bin are sorted for restocking.
4. Someone, most likely a pharmacy technician takes the sorted medications and places them back into pharmacy stock.
5. The medications are now ready for use.

Notice that step number three above is highlighted in red. This is the step in the process that is most open to error.

Let’s just say that during the sorting process the medications are not sorted properly and a hydrALAZINE tablet finds its way into a hydrOXYzine bin. I’ve seen this happen many, many times. The packaging and names are similar so the single hydrALAZINE tablet goes undetected in the wrong bin. So the next time hydrOXYzine is needed in bulk, i.e. for an ADC replenishment, the hydrALAZINE ends up in the pile of hydrOXYzine tablets. Since the tablets are loose, the pharmacist checking the bag full of hydrOXYzine fails to see the single hydrALAZINE tablet.

The hydrALAZINE is mistakenly sent to an ADC cabinet along with the hydrOXYzine where a nurse pulls the hydrALAZINE from the ADC thinking it is hydrOXYzine. Sometimes the nurse fails to recognize the error and the hydrALAZINE is administered to the patient in place of hydrOXYzine.

Hopefully the facility utilizes BCMA and the error is avoided. However, only about 35% of hospitals in the country were using BCMA as of 2010(3). However, if the facility is not utilizing technology like BCMA, the incorrect medication is administered to the patient where it could potentially cause harm.

Although the example above involves several failures during the medication use process, it all began with a breakdown during the restocking phase. I’ve seen this exact error many times during my career, as well as many others caused by sound-alike-look-alike medications.

It’s clear to me that the return/restocking phase of the medication distribution process is the weakest link, and is rarely acknowledged when thoughts of improving the process come to mind. So what’s the answer? Does the process need to be automated or is a better manual process the answer? I don’t know what the solution is, but I think it’s time we gave it some thought.

References

1. Leape L.L., D.W. Bates, D.J. Cullen, J.W. Cooper, H.J. Demonaco and T. Gallivan et al. 1995. “Systems Analysis of Adverse Drug Events.” ADE Prevention Study Group. JAMA 274: 35-43.
2. Bates D.W., D.J. Cullen, N. Laird, L.A. Petersen, S.D. Small and D. Servi et al. 1995. “Incidence of Adverse Drug Events and Potential Adverse Drug Events: Implications for Prevention. ADE Prevention Study Group.”JAMA 274: 29-34.
3. Pedersen C.A., Schneider P.J., Scheckelhoff D.J. 2011. “ASHP National Survey of Pharmacy Practice in Hospital Setting: Prescribing and Transcribing – 2010” Am J Health-Syst Pharm 68: 669-88.

The video below talks about the integration of smart pumps with Cerner at WellSpan Health in New Jersey. Interesting stuff.

Data surrounds us. It’s in everything we do, from the bank statements we receive in our personal life to the mountains of data collected by every healthcare institution. Regardless of the data collected, there are basically three things that can be done with it. Data can be ignored, it can be archived or it can be used. Unfortunately only one of those three things is truly useful; using it. Many people chose to ignore or archive data not because the information isn’t valuable, but because they are overwhelmed with the amount of information they receive and the way that the information is presented.

Presentation is everything when it comes to data. The methods we chose to present information can make the difference between the information being useful or being useless. The significance of such a problem creates a quagmire for pharmacists as theirs is a data driven environment. Pharmacists spend a great amount of time emerged in data; patient data, lab data, micro data, kinetics data, drug data, usage data, nursing data, physician data, and so on.

Data visualization and dashboards can help. They provide us with the tools to better understand the information around us, and therefore improve efficiency in the process.

Data visualization
Acording to an article by Michael Friendly in 2008 (1) data visualization is “information which has been abstracted in some schematic form, including attributes or variables for the units of information”. In other words it’s data that’s put on display in a format that’s easier for the end user to understand, i.e. the use of an image to represent tables full of data.

It’s difficult to conceptualize the benefits of data visualization until you see it in action. This was recently demonstrated to me at the unSUMMIT in the form of a poster on data visualization by Charles Boicey, MS,RN-BC, PMP, Informatics Solutions Architect from the University of California, Irvine Medical Center. The poster demonstrated the value of data visualization by utilizing several different methods to present information collected from bar-code medication administration (BCMA) override scans. The information was displayed in table format along with various types of graphs and images. The tabular information was virtually useless as it was difficult to wade through the data and make sense of it. However, the visual representation of the data created a much more powerful statement that made the data easier to understand.

According to Vitaly Friedman (2) the “main goal of data visualization is to communicate information clearly and effectively through graphical means”. While the concept is simple, the application is more difficult and requires a keen eye and the ability to think in abstract ways. If you can get it right, it’s powerful stuff.

Dashboards
Dashboards take data visualization one step further by aggregating several different pieces of visual information in a single location. Think of it as an information control panel where the end user controls what information is gathered and how it’s presented. A simple search for “dashboards” in Google Images reveals several excellent examples.

Even though the concepts are useful and commonly used in business applications, the use of data visualization and dashboards remain relatively uncommon in healthcare, which is unfortunate because they could go a long way in helping pharmacists understand what’s really going on around them.

References:
(1) Michael Friendly (2008). “Milestones in the history of thematic cartography, statistical graphics, and data visualization”

(2) Vitaly Friedman (2008) “Data Visualization and Infographics” in: Graphics, Monday Inspiration, January 14th, 2008

The presentation focused on the often overlooked things that need to be done following implementation of something like BCMA. Healthcare systems have a bad habit of not providing enough resources, both labor and monetary, to maintain and optimize technology once implemented. I simply suggested five things that healthcare systems could do post-implementation to make sure their BCMA implementation didn’t crumble right before their eyes.

And now that the unSUMMIT presentation has been delivered I am officially retiring from the role of presenter. Unlike some people I know, it takes me a concerted effort and a fair amount of time to put one of these things together, and I just don’t feel like doing it again. Enjoy.

From the unSUMMIT website:

Conventional summits deliver a something-for-everyone survey of the landscape with little or no depth on any given topic. This warp-speed flight provides only a 30,000-foot view of the terrain below. Nurses, pharmacists, and IT professionals return to the trenches of their own hospitals no better equipped to dig in and implement change.

The unSUMMIT is different. It delivers a steadfast focus on barcode point-of-care technology. Attendees are outfitted with practical tools, insight, and inspiration for leading their institutions to carefully select, implement, and harness the quality-improvement power of BPOC systems.

Truly an unconventional convention, The unSUMMIT is designed to get you out of the clouds and into the weeds, where the union of technology and practice can be more easily realized through the shared expertise of your experienced colleagues.

I think most people believe that the unSUMMIT is nothing more than a bunch of people sitting around talking about BCMA, but it actually goes beyond that. Last year I heard presentations on not only bar-coding medications, but integrations of smartpumps into eMARs, the use of RFID tags, how to conduct observational studies and so on.

This year looks to provide a similarly broad scope of information. While reviewing the list of presentations I saw topics on mobile technology, accountability, technology roadmapping, workflow design and of course a lot of stuff on bar-coding medications.

The unSUMMIT begins officially tomorrow morning. I will be presenting on Thursday, April 28 at 2:00pm. I haven’t decided if I’m going to post the presentation here or not. I’ll let you know.

If you’d like to know what’s going on during the conference you can follow the Twitter stream at #unSUM11.

The Codonics SLS Safe Label System is based upon the SmartLabels technology licensed from Massachusetts General Hospital. The system was developed by anesthesiologists at Massachusetts General Hospital to prevent intravenous medication errors via barcode assisted medication labeling. At the 2008 ASA Annual Meeting, the system was awarded the Ellison C. Pierce Award from the Anesthesia Patient Safety Foundation for best scientific exhibit in patient safety.

Massachusetts General Hospital SLS Article

A 2009 study done by Massachusetts General Hospital with a Smart Label System evaluated compliance with The Joint Commission, ASA medication labeling requirements, patient safety, and clinician communication. The study evaluated five ORs where the labeling system was installed and compared them to manual syringe preparation by clinicians. The results showed 100% compliance was obtained using the automated system while less than half of the syringes prepared by the clinicians using traditional methods met TJC requirements. Clinicians were found to be very accepting of the system into their workflow, citing ease of use and utility of the safety features, such as audio and visual read-back of the data provided by the system. In addition to The Joint Commission labeling requirements, the system’s labels include date and time of preparation and expiration for all medications, are color-coded according to the ASA’s guidelines, and carry a 2D barcode of essential information that allows integration with an AIMS.

Recent News: “Automated Labeling Promises Smoother, Safer OR”
(originally published in the May 2010 issue of Anesthesiology News)

SLS Patient Safety Features
• Visual and audible confirmation of each drug name and concentration
• Visual and audible indication of non-usable drugs
• Configurable formulary of site-specific medications available with purchase of the SLS Administration Tool software license
• Automatic calculation and labeling of expiration

Safety Features Possible When Integrated with an AIMS
• Identification of each syringe to be administered
• Warnings for expired syringes when scanned
• Warnings for patient allergies or adverse drug interactions

The system utilizes an older version of Windows Mobile on a clunky Motorola handheld. To get from log-in to a useful place in the application required me to go through no less than four screens. The touch screen was unresponsive and difficult to use, the device was painfully slow and the connectivity was lacking.

So, to sum up my experience with PARx – used with carousel technology it’s great, but try to use the standalone product and you might find yourself spewing profanity.

I don’t often see articles that talk about using FMEAs, which is a real shame secondary to their value. So it was a pleasant surprise to see a recent article in Pharmacy Purchasing & Products on the use of an FMEA post BCMA implementation. I’m not familiar with using an FMEA after the fact, but it makes more sense to me now after reading the article.

According to the author, they “had conducted an FMEA prior to initially employing BCMA; however, we never performed any post implementation follow-up on the system.” An all too common occurrence in healthcare, i.e. implement and forget. We did something similar at Kaweah Delta when I worked there, but we referred to the process as a gap analysis rather than calling it an FMEA. Regardless of the verbiage, the results were similar.

The reason cited for the second FMEA was an increase in errors associated with the BCMA system. “Errors were primarily due to unscannable bar codes, mislabeled medications, the wrong medications being dispensed, and most commonly, nursing staff’s failure to scan.” This sounds familiar. The errors cited are simply side effects of the implement-and-forget mentality. Regardless of the system in place, humans inevitably develop bad habits and workarounds. We need to be constantly reminded to do the right thing. Implementation is only a small part of the work involved with any new system. Follow-up, maintenance and optimization is when the real work begins.

And the results of the second FMEA? “Three months after completing the FMEA, the team compared the before and after scan rates. We found significant improvements in the scanning of both the patients and the medications throughout the system. In addition, we have witnessed a culture change: nurses now become anxious if they cannot scan a product.” Not bad.

Read the article, it contains some good information.