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.

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.

Hospital Pharmacy: “During the process of with drawing a patient’s nicotine patch from an automated dispensing cabinet (ADC), a carousel pocket opened to reveal 2 nicotine patches and 1 fentaNYL 50 mcg/hr patch. The nurse using the ADC immediately called the pharmacy to report the discrepancy. The pharmacy investigated and found that it was not a dispensing error. Both patches (nicotine and fentaNYL) were stored in the same medication carousel, and the fentaNYL patch slipped over the top of one pocket and into another pocket that contained nicotine patches. Generally, the hospital reserved ADC carousel pockets for controlled substances, but there was a history of pilferage of the nicotine patches when stored in matrix drawers. To deter pilferage, the pharmacy began stocking them in secure carousel pockets with the tracking feature on to count the product. FentaNYL was in a nearby pocket by itself, but when the carousel turned, patches sticking up from the fentaNYL pocket were caught and dragged to another pocket that housed nicotine patches.” - This type of occurrence is more common than you might think. To prevent this type of thing from happening, many hospitals will utilize a system similar to the Pyxis CUBIE system. Pyxis CUBIE pockets are small containers with a clear plastic lid. The lid remains closed until that medication is accessed via the Pyxis medication terminal. This prevents items from jumping to another location.

ADUs provide varying degrees of access to medications for distribution to patients. The machines are located on the nursing units for obvious reasons and offer great advantages to pharmacy. Some of these advantages include:

ADUs are filled with medications in ready to use, unit-dosed packages. Pharmacies don’t always receive medications in unit of use packaging and will often times unit-dose the items from bulk containers prior to placing them in the dispensing machines. Our bulk packager of choice is AutoPack from Talyst. There are other, similar products on the market, but none offer the same cluster of conveniences as Talyst.

Talyst has a system similar to AutoPack called InSite that is used specifically in Long Term Care (LTC) facilities and prison systems. With InSite loose tablets are placed in a medication canister fitted with a computerized chip used to identify the medication contained inside. Instead of unit dosing the bulk tablets prior to placing them in an ADU, the canisters are placed directly into InSite where they are unit-dosed on demand. For all intents and purposes, InSite becomes the ADU (more information can be found at the Talyst website). In LTC this eliminates the need for the familiar “punch cards” thus reducing waste, and makes access to medications much easier for nursing. The system reminds me a lot of our AutoPack unit.

As I look at the InSite system I wonder if a similar system could be used in the acute care setting. Some customization would be necessary, but it would eliminate the intermediate step of having to unit-dose bulk medications prior to loading them in the ADU. Currently we not only unit-dose medications on demand, but store them in our automated carousel as well. Placing the packager on the floor would eliminate the need to store the unit-dosed items in the pharmacy. We currently stock our ADUs with enough medication for between 14 and 30 days, so placing an entire bottle of something in a canister for use on the floor wouldn’t be excessive. Of course this is dependent on the medication, the nursing unit and typical use patterns.

I immediately see three advantages to using an on demand unit-dose dispensing system on the nursing unit:

1. Decrease the amount of technician and pharmacist time in the pharmacy. The process of unit-dosing a medication in the pharmacy currently consists of a technician filling the medication canister, a pharmacist checking the canister, the technician unit-dosing the item and finally the pharmacist signing off on the final product (not including the pull and check prior to loading in the ADU). The item is then taken to the floor and placed in the ADU. If the bulk packager was taken out of the pharmacy and placed on the nursing unit, the process would look something like this: the technician would fill the canister, the pharmacist would check it and it would be taken to the floor and placed in the packager at the nurses station. The location of the canister in the packager is irrelevant because the canister and medication are identified via the embedded computer chip. In other words, you can’t put the canister in the wrong location.

2. Increased storage space. There would be no need to store unit-dosed medications in the pharmacy that were already available in bulk on the nursing unit.

3. Increased safety by eliminating a step in the distribution process. If you want to increase efficiency and increase safety, simplify the process. Adding steps can only increase your risk for mistakes. See the AHRQ website for an interesting piece on safety and unit-dose packaging.

A system like this would not be without it’s difficulties. Adding yet another dispensing machine to each nursing unit would be costly as well as create integration issues. Also the space needed for this scenario will likely be larger than current methods. However, the dynamics of a system that provides the access of a current AUD like Pyxis, combined with the on demand unit-dose dispensing capabilities of a system like InSite would be pretty slick. It’s just a thought.