Saturday morning coffee [December 27 2014]

“A man who lives right, and is right, has more power in his silence than another has by his words.” ~Phillips Brooks

So much happens each and every week, and it’s hard to keep up sometimes. Here are some of the tabs that are open in my browser this morning along with some random thoughts….

A package arrived on my doorstep Christmas Eve. That’s not unusual this time of year. However, neither my wife nor I were expecting a package. When I opened it I found two coffee mugs inside with a note that said “We were inspired by your blog post the other day”. Very cool. The mugs were sent by MEPS Real-Time, Inc. A very big thank you to the generous people at MEPS.

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Continue reading Saturday morning coffee [December 27 2014]

ISMP responds to deadly drug error in Oregon

Last week I wrote about the tragic death of a patient caused by a drug error (CSP error results in death of a patient). One day later on December 18, 2014, ISMP also addressed the error in the Acute Care edition of their biweekly ISMP Medication Safety Alert, i.e. one of their newsletter. I had hoped that ISMP was going to provide much greater detail and insight into the error, but that’s not the case. At least not at this point, anyway.

I had hoped to find out what occurred in the pharmacy to allow such a mistake to happen. Perhaps more details will come to light as time goes on. All we can do is wait.

With that said here are some things from ISMP worth noting:

To prevent inadvertent use, identify neuromuscular blockers available within your organization and where and how they are stored. Regularly review these storage areas, both inside and outside of the pharmacy, including agents that require refrigeration, to consider the potential for mix-ups.

Limiting access to these products is a strong deterrent to inadvertent use. Consider limiting the number of neuromuscular blockers on formulary, and segregate or even eliminate storage from active pharmacy stock when possible.

Restrict storage of paralyzing agents outside the pharmacy and operating room by sequestering them in refrigerated and nonrefrigerated locations.

ISMP recommends highly visible storage container for neuromuscular blockers (one example here: www.ismp.org/sc?id=458).**

ISMP recommends affixing warning labels on vials and admixtures that clearly communicate the dangers of neuromuscular blockers.**

ISMP recommends the use of IV workflow technologies. “Now is the time for hospital leadership to support the acquisition of IV workflow technologies that utilize barcode scanning of products during pharmacy IV admixture preparation.” While the article lists only three systems, there are several on the market [see  In the Clean Room TOC for a current list of many of the available systems].

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**I know that many think this is a good idea, but I’m not so sure that I’m one of them. On the surface, using highly visible storage containers and labels might seems like a good idea, but over time people become used to the idea and become blind to the differences. In addition, over the years the number of items that require alternate storage and labeling has grown, making differentiation “the norm”. It’s like the student that highlights everything in the textbook with five different colors. Eventually the entire book is highlighted, making the process meaningless to the reader.

Saturday morning coffee [December 20 2014]

“Christmas is the spirit of giving without a thought of getting. It is happiness because we see joy in people. It is forgetting self and finding time for others. It is discarding the meaningless and stressing the true values.” ~Thomas S. Monson

So much happens each and every week, and it’s hard to keep up sometimes. Here are some of the tabs that are open in my browser this morning along with some random thoughts….

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Continue reading Saturday morning coffee [December 20 2014]

CSP error results in death of a patient

A 65-year-old woman died at St. Charles Medical Center in Oregon after being given an infusion of rocuronium instead of fosphenytoin.

“The prescription was entered correctly into the electronic medical records system, and the pharmacy received the correct medication order, the AP reported. The IV bag was also labeled properly. After the pharmacy worker mistakenly filled Macpherson’s IV with rocuronium, a second employee did not catch the error while checking the vials of medication and the IV bag for the 65-year-old patient.” (via: Pharmacy Times).

As details of the tragedy continue to emerge, here’s what we know so far:

  • An infusion of fosphenytoin was ordered for the patient, presumably a piggyback.
  • Instead of fosphenytoin (anti-seizure med) the patient received rocuronium (a paralytic)
  • It is unclear at what point in the compounding process, if at all, the infusion was verified by a pharmacist. According to the article “a second employee did not catch the error while checking the vials of medication and the IV bag”. Not entirely sure what that means.
  • The infusion was hung
  • A fire alarm sounded
  • The nurse closed the patient’s door and didn’t check on her for 20 minutes. That was more than enough time for the drug to cause irreparable harm to the patient.

It is unclear what process was used to make the infusion, or what safety safeguards were in place. The real shame here is that there are any number of available technologies that could have prevented the error. Any of the semi-automated workflow management systems on the market today would have worked. Bar code scanning, gravimetrics, perhaps image assisted verification, etc. Take your pick.

According to an article from The Bulletin “To help prevent similar mistakes from happening, the hospital’s pharmacy has begun placing orange stickers on IV bags containing paralytic agents that indicate what’s in them. [The patient’s] IV bag had a blue sticker indicating it was a neuromuscular agent, which Boileau [Dr. Michel Boileau, St. Charles’ chief clinical officer], said both fosphenytoin and rocuronium are.” Not exactly sure how using orange stickers instead of blue is going to do much. Seems kind of silly. I think I’d start looking at something a little more aggressive. I’d also rethink my classification of both fosphenytoin and rocuronim as “neuromuscular agents”. I think I’d call fosphenytoin a hydantoin anticonvulsant and rocuronium a nondepolarizing neuromuscular blocker. They’re clearly not the same class of drug.

It will be interesting to see how organizations like ISMP and ASHP respond to this latest error.

Saturday morning coffee [December 13 2014]

“A doctor who works without error is not a genius. He is a liar.” ~unknown

So much happens each and every week, and it’s hard to keep up sometimes. Here are some of the tabs that are open in my browser this morning along with some random thoughts….

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Continue reading Saturday morning coffee [December 13 2014]

#ASHP Midyear final thoughts

I concluded my time at ASHP Midyear in Anaheim on Tuesday evening. Here are my parting thoughts.

  • The show felt more lively this year than the past couple. It’s hard to explain, but it felt like people were interested in everything around them; a good sign.
  • There was an infusion of new products in the exhibit hall. The “normal” stuff was there, but it is clear that the vendors are once again ramping up. The introduction of meaningful use several years ago put a stranglehold on pharmacy budgets and projects. Everyone put all their eggs in one basket, i.e. all resources redirected to a single goal. During that time hospital pharmacies entered a black hole in regards to the implementation of new technology. It appears that equilibrium has been restored.
  • The “Pharmacy of the Future” Pavilion was anything but the pharmacy of the future. It was nothing more than a giant advertisement for the vendors. Nothing stood out as futuristic.
  • There was virtually no discussion/exhibits for track and trace. Given the state of H.R. 3204, the Drug Quality and Security Act (DQSA), this is going to be a big deal over the next several years. I expected to see more. Then again, the exhibitors have to reserve their booths a year in advance. Hard to plan around that.
  • Didn’t see much to do with Telepharmacy. In fact, I can only think of a single exhibit and that was an outpatient system.
  • The acquisition of CareFusion by BD is interesting for several reasons, but I wonder how the two companies will handle their i.v. workflow management systems. CareFusion has PyxisPrep and BD has BD Cato. Given the limitations of PyxisPrep in its current state it would be hard for me to imagine them not going with BD Cato as their flagship system in the i.v. room. Only time will tell.
  • The acquisition of CareFusion wasn’t the only big move that BD made this year. Apparently BD has partnered with Aethon for medication tracking outside the pharmacy.
  • Envision’s exit from the i.v. workflow management space should be interesting. With their intellectual property for image capture/remote verification going to BD, I wonder what will become of the rest of the product, i.e. the software. The product had a solid foundation and some nice functionality. Hmm, gives me a couple of ideas.
  • APOTECA was conspicuously absent from the exhibitor floor. I found that odd considering that they are one of only two manufacturers of hazardous compounding robots in the U.S. The company also introduced a semi-automated i.v. workflow management system, APOTECAps earlier this year. I fully expected to see the products on display at ASHP Midyear. Not the case.
  • Omnicell entered into an agreement with Baxter to both sell and integrate with DoseEdge. This should allow Omnicell to track CSPs prepared with DoseEdge throughout their suite of products. Everyone is scrambling to get into the i.v. room.
  • As mentioned previously, Closed System Transfer Devices (CSTDs) seemed to be popular among the exhibitors. At least three separate companies – EQUASHIELD, BD, ICU Medical – were showing off their products. I’m not surprised with USP <800> looming in the not too distant future.
  • RFID seems to finally be picking up some steam in pharmacy practice. Several companies were displaying RFID solutions. Several others announced partnerships with those same companies. The most popular areas for RFID appear to be refrigerated inventory management, anesthesia, and medication trays/carts.

More from #ASHP Midyear

Yesterday was more of the same, i.e. I spent several hours in the exhibit hall yesterday trying to make my way through my “game plan”. And again I failed to complete my mission. I spent a lot of time speaking to various people about some of the things I saw on Monday.

Some of my stops and thoughts from yesterday:
Continue reading More from #ASHP Midyear

CareFusion announces partnership with Kit Check at #ASHP Midyear

Last night I attended the first ever CareFusion Insider Event held at ASHP Midyear. The event was designed to spotlight CareFusion and their product line. Some new things were announced like the introduction of a Pyxis Mini and a new focus for the Rowa Dose System. CareFusion has had the Rowa Dose System for a while, but it was initially targeted at markets outside the U.S.

Something I hadn’t expected was an announced partnership with Kit Check. I have written about Kit Check and Anesthesia Check before.

According to the press release “today announced the companies will partner by connecting their hardware, software and RFID solutions to offer improved efficiency and accuracy in medication handling from pharmacy dispensing to OR point of use”.

It’s unclear how deep the integration will run, but it’s clear after last night’s event that CareFusion is pushing a more integrated approach across the entire healthcare continuum.

I’ll be stopping by both the Kit Check and CareFusion booths over the next couple of days to find out more.