Jerry Fahrni

Author: Jerry Fahrni

  • 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….

    MUG_SMC
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  • Thoughts on my technology loadout for ASHP Midyear

    As mentioned previously, I used ASHP Midyear to experiment with my technology loadout. My equipment consisted of a Yoga 2 Pro, a Surface Pro 3, and a Samsung Galaxy S5. Was it successful? Let’s find out.

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  • #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:
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  • #ASHP Midyear 2014 update

    I spent several hours in the exhibit hall yesterday trying to make my way through my proposed “game plan”. Didn’t even get close. I kept getting sidetracked by one thing or another.

    Stops I did make were all interesting, and included:
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  • 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.

  • Saturday morning coffee [December 6 2014]

    “The happiest people don’t have the best of everything, they just make the best of everything” ~unknown

    Welcome to December. Hard to believe that Christmas is right around the corner.

    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….

    MUG_SMC
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  • My ASHP Midyear 2014 technology loadout

    I’m always tinkering with my travel bag to find just the right mix of computer technology and carrying convenience.

    Most recently I’ve been carrying a Yoga 2 Pro, an Asus VivoTab 8, and a Samsung Galaxy S5. The Yoga 2 Pro serves as my primary machine for pretty much everything. The VivoTab 8 is an 8-inch Windows 8 tablet with Wacom digitizer, i.e. pen support. I use it to take notes, mark up PDFs, etc. I find that it’s just “okay”. The 8-inch screen is too small at times, and lately the digitizer has been finicky; a known issue with this tablet. The S5 goes everywhere I do. I use it for the obvious things – calls, text messages, emails, etc – as well as to play games, listen to music, take photos, check my social media feeds, and so on.

    I’m changing things up a little this trip. My loadout for ASHP Midyear will include:

    • Yoga 2 Pro – This is my primary workhorse. It’s a great machine and meets almost all my computing needs. I will be using it to compose blog posts and manage photos and videos that I capture while walking around the exhibit hall.
    • Surface Pro 3 – New this year, the SP3 will likely go with me everywhere I go while I’m at Midyear. It’s small and light enough that I can carry it around, it offers great pen support for note taking, and still has plenty of horsepower for when I need more than a tablet. I thought about leaving the Y2P at home and taking only the SP3, but I’ve never traveled without a “real laptop”. I’ll see how things go during Midyear. If things work out then I’ll leave the Y2P at home next time. Can the SP3 really replace my laptop? I don’t know, let’s find out.
    • Galaxy S5 – As mentioned above, this is my primary mobile device. I’ll be using it to handle my calendar, make calls, send texts, read and respond to emails, etc. I will also be using it to take photos and videos when possible. I thought about taking my Sony Handycam for video, but decided against it for two reasons. First, it’s another piece of hardware to carry around. Second, I don’t know if vendors will allow me to walk around shooting video of everything they demo. For those that allow me to take video, I’ll have my S5.

    In addition to the three machines above, I’ll also be carrying various cables, adapters, and external chargers for my smartphone.

    And there you have it, my ASHP Midyear 2014 technology loadout.

  • #ASHP Midyear 2014 game plan

    ASHP Midyear is next week in Anaheim, California. I arrive in Anaheim on Sunday afternoon, and will be there until Wednesday morning. I always look forward to Midyear as it gives me an opportunity to connect with friends I haven’t seen in a while and learn some new things.

    One of the great benefits that Midyear offers me is an opportunity to look at large amounts of pharmacy automation and technology in one place at the same time. Midyear is the only place where you will find so many vendors in one space. The exhibit hall is typically full, and it’s where I spend a lot of my time.

    While I enjoy visiting with all the exhibitors, limited exhibit hall hours means that I have to prioritize where I spend my time.

    My must-see list this year includes:
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