Managing medication trays in acute care pharmacy

Medication trays – a.k.a. med trays, code trays/kits/boxes/bags, transport trays/kits/boxes/bags, intubation kits, C-section trays, anesthesia trays, and so on ad infinitum – are common in acute care pharmacies.  I’ve seen them in every variation you can imagine in every pharmacy I’ve ever been in.

Depending on the situation, med trays can contain a large number of injectable medications. For example: code trays may contain several different neuromuscular blockers like vecuronium, rocuronium, succinylcholine; pressors like epinephrine, norepinephrine, phenylephrine;  other code drugs like atropine, vasopressin; reversal agents like naloxone and neostigmine; antibiotics, etc, while a C-section tray may contain local anesthetics in various shapes and sizes (lidocaine with or without EPI, SDV or MDV, bupivacaine of various concentrations, etc). The list goes on. It’s pretty crazy.

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Automated intravenous fluid monitoring at the bedside

Over the years I’ve had a lot of ideas, some good and some not. When an idea comes to me I typically record it in a notebook that I have sitting on my desk. Occasionally I return to the notebook and review the ideas to see how many of the ideas still have merit. Sometimes an idea has become outdated, and rarely an idea will have materialized as a product of similar design built by a company. And then there’s a group of ideas and concepts that still hold value, but haven’t been seen in the market.

Today I was rummaging through some of my old ideas. One of them from 2010 caught my attention. In 2010 I thought it would be cool if someone could use technology to analyze the IV fluid being administered to a patient in real-time. Basically such a system would prevent the wrong IV medication from being hung on a patient, thus preventing a medication error.
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Cleanroom technology for pharmacy – DRUGCAM

DRUGCAM is an interesting piece of pharmacy cleanroom technology. On one hand it falls into the semi-automated systems category because the person using it has to manually manipulate all the components of the sterile compound they’re making. In other words, it’s not a robot. On the other hand DRUGCAM uses some interesting technology and software to automate some of the steps in the process.

DRUGCAM uses multiple cameras(1) to automatically detect the items being used during the compounding process. As the user passes components in front of the cameras, the system automatically identifies them. No bar code scanning required. That’s probably a good thing outside the U.S. as I’ve learned that not all countries require manufacturers to place a bar code on their drug containers. If the system doesn’t recognize the item, the user is notified via visual cues on the screen.

DRUGCAM uses the same technology to automatically detect the volume of fluid pulled into syringes, and also detect when the same syringe is empty following addition of the contents to the final container. I’m not sure how the system determines the correct syringe position, but it’s pretty interesting.

One other thing that makes DRUGCAM unique is that it takes video of the entire compounding process. I’ve mentioned this idea to several vendors over the past few years, but no one really seemed interested in the idea of using video.(2) I think it offers potential advantages over still photos. For one, if something looks weird you can always move forward or back in the compounding process to see what went wrong.

Check the video below. It shows DRUGCAM being used in a glovebox.

DRUGCAM is not currently available in the U.S. If you’d like more information just follow the link to the DRUGCAM website.


(1) When I saw DRUGCAM at the ASHP Summer Meeting back in June 2013 the engineer told me that the system utilized two cameras, but I can’t find that information on the product website.
(2) Everyone I’ve talk with was concerned about the storage requirements for the video. My brother works for a company that designs security cameras, software, etc. Those companies have been dealing with high-definition video storage for years.

Saturday morning coffee [March 21 2015]

“Life is a dream for the wise, a game for the fool, a comedy for the rich, a tragedy for the poor.” – Sholom Aleichem

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….

I was sitting in The Main Street Café in Visalia, CA having breakfast with my brother when I saw the sign below hanging on the wall. Perk ‘Em Up….would make a great name for a coffee shop, no? Just in case you were wondering, the staff was great, but the food was mediocre. The pancakes weren’t very good at all. No flavor. Bacon was good though.

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Drug shortages, whose to blame?

Medscape: “One cause of these shortages, pharmaceutical companies charge, is the amount of time it takes the DEA to approve controlled substance quotas. The DEA has created these quotas for each class of controlled substances and for each manufacturer of drugs containing these agents to prevent their diversion to illegal uses.”

The drug shortage problem is nothing new. It has become an everyday reality of pharmacy practice. ASHP has established a dedicated website for the problem, and the FDA has gone as far as to create a mobile app to help people track shortage information.

For most people the idea of a drug shortage seems silly, i.e. just make more. The problem is more complicated than that, however. The causes of drug shortages are multifaceted.
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Saturday morning coffee [March 14 2015]

“There is nothing in which people more betray their character than in what they laugh at.” – Goethe

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….

The mug below comes straight from Voodoo Doughnuts in Portland, OR. My wife and youngest daughter were up North last week visiting colleges. They surprised me upon their return with a box of Voodoo Doughnuts and this mug. The doughnuts were delicious.

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Applications to assist with Antimicrobial Stewardship

A couple of days ago I wrote about The California Antimicrobial Stewardship Program Initiative, and how it’s an opportunity for pharmacists to get out and stretch their clinical legs.

Antimicrobial stewardship requires a lot of real-time surveillance and monitoring of patients, labs and cultures, medication use, and so on. There are basically two ways to accomplish this. One is tedious and inefficient, while the other is smart and efficient.

The tedious, inefficient method is the one used by many healthcare facilities. Pharmacies in these facilities simply throw pharmacists at the problem by having them look at a bunch of patients manually every day in search of anomalies. It’s very time consuming. It’s like looking for a crooked needle in a needle stack.

The smart, efficient method involves the use of clinical decision support systems. These systems are connected to several data feeds from other systems throughout the hospital, such as ADT, pharmacy, lab, and so on. The data is aggregated and analyzed against a set of rules designed to find patients with potential problems. These patients are tagged and referred to a pharmacist for follow up, i.e. the pharmacists are only presented with the crooked needles. It’s a much better way to go about things.

There are several systems on the market designed to perform real-time surveillance and clinical decision support. The list below includes many, but is certainly not exhaustive.

Antmicrobial Stewardship, an opportunity for pharmacists

Interesting little blurb in the March 1, 2015 edition of AJHP that talks about a new California law that will require acute care hospitals to practice antimicrobial stewardship. The law goes into goes into effect July 1, 2015. [Paywall access to the article]

What’s antimicrobial stewardship? Well, according to the Infectious Disease Society of America (IDSA), the term “refers to coordinated interventions designed to improve and measure the appropriate use of antimicrobials by promoting the selection of the optimal antimicrobial drug regimen, dose, duration of therapy, and route of administration.  Antimicrobial stewards seek to achieve optimal clinical outcomes related to antimicrobial use, minimize toxicity and other adverse events, reduce the costs of health care for infections, and limit the selection for antimicrobial resistant strains.” Pretty straight forward.

ASHP has an official statement on the subject – The Pharmacist’s Role in Antimicrobial Stewardship and Infection Prevention and Control – which can be found here.

In the document ASHP states that “pharmacists have a responsibility to take prominent roles in antimicrobial stewardship and infection prevention and control programs in health systems. Pharmacists should participate in antimicrobial stewardship and infection prevention and control efforts through clinical endeavors focused on proper antimicrobial utilization and membership on relevant multidisciplinary work groups and committees within the health system.” I agree. It’s a no-brainer. I’ve always felt that pharmacists were well suited for this kind of thing. After all, most of what antimicrobial sterwardship is all about requires a deep understanding of when and how to use antibiotics.

ASHP states that it is the responsibility of pharmacists to promote optimal use of antimicrobial agents, reduce the transmission of infections, educate healthcare professionals, patients, and the public. All important tasks, but nothing that a good pharmacist couldn’t handle.

Unfortunately the new California law doesn’t specify that a pharmacist must participate in the antimicrobial sterwardship program. The law indicates that the stewardship team within hospitals must include “at least one physician or pharmacist who has expertise and training in antimicrobial stewardship“. No guarantee that an acute care facility will opt to include a pharmacist, but at least there’s a chance.

Saturday morning coffee [March 7 2015]

“Your reputation is in the hands of others. That’s what a reputation is. You can’t control that. The only thing you can control is your character.” – Dr. Wayne W. Dyer

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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5 years later, my thoughts on pharmacy practice

I haven’t been a practicing pharmacist in the traditional sense in about five years. I’ve spent the last 19 months as an independent consultant, which has been awesome. Prior to that I was a Product Manager for about two and a half years at a company that dealt in pharmacy automation and technology. Before that I was an IT Pharmacist, which did give me an occasional glimpse of “pharmacy practice”, but overall I figure it’s been at least 5 years since I worked at earnest as a staff pharmacist.

Recently I took a per diem position in a large acute care hospital as a staff pharmacist. I’m completely content being a consultant, and have enjoyed it very much, but I felt that I was losing touch with the daily grind that is pharmacy. I needed to get my hands dirty again and make sure that I wasn’t giving advice to people that was out of touch with reality. I think it’s important for any consultant to be able to relate to the actual problems that they’re being asked to solve. So for the past few months I’ve been staffing about a day a week. Below are some thoughts on what I’ve seen and heard.
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