Jerry Fahrni

Author: Jerry Fahrni

  • Automating the oral pediatric syringe filling process [idea]

    oral syringeThe distribution process in pediatric acute care can be quite a bit different than its adult counterpart. The basics are the same on the surface: 1) receive medication orders, 2) fill medication orders, 3) dispense medications. The big difference however is how those medication orders are filled. Pediatric patients require a lot medications in liquid form pulled into oral syringes with patient specific dosages. The bummer is that a vast majority of these syringes are not manufactured in unit of use syringes. In other words you have to do most of the work yourself. It’s a bit of a hassle, but it has to be done. The process of pulling liquid doses into oral syringes has more in common with work done in the IV room than it does with traditional oral solid distribution.

    Recently I was visited a pediatric hospital and watched this process in action. Based on what I witnessed I started to wonder if it was possible to automate the process. And if you could automate it, would it offer any benefit? I suppose it could increase the safety of the process as well as potentially eliminate the need for a pharmacist, freeing them to do something else. Maybe. Maybe not. Regardless, it was worth more thought.

    I started breaking down the process and realizes that it’s more complex than it appears on the surface; it always is. Automating the process would be difficult. Several pieces of the puzzle are already available today, but as completely disparate systems.

    Just thinking out loud, or in writing as the case may be, the process would look a little like this:
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  • Xenex device uses UV light to kill infectious organisms

    I thought this was pretty cool. Simple, yet effective.

    Syracuse.com: “St. Joseph’s Hospital Health Center has stepped up its war against potentially deadly patient infections by unleashing killer robots. The hospital is using two robots, that resemble R2D2 from Star Wars, to kill germs in patient rooms with powerful blasts of ultraviolet light. After trying out the device last summer, St. Joe’s quickly saw a more than 50 percent decrease in its rate of Clostridium difficile – C. diff for short – infections. That highly contagious bug is rampant in hospitals and nursing homes. It can make patients very sick and sometimes kill them.” – That’s a big deal, especially when you’re talking about something as problematic as C. diff.
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  • Who should drive the selection of pharmacy automation and technology?

    Who should be the driving force behind the selection of new automation and technology in a hospital pharmacy? It’s a simple question really, and in my mind there’s only one clear answer: pharmacy should drive the selection of their own automation and technology. That makes sense, right? Well it certainly does to me.

    However, lately I’ve seen a disturbing trend when talking with hospital pharmacies about their selection process. It appears that the IT department – you know, those guys that configure computers and keep your network and hospital servers humming along – has been given a lot of authority in the selection process. Call me crazy, but that seems a little strange to me.

    I’ve always thought of IT as a service department, someone to help you accomplish your goal when it involves technology. As an IT pharmacist it was my job to look at pharmacy automation and technology, evaluate it, weigh the pros and cons, and make a decision based on what was best for the goals of the pharmacy. Once that was done I would get IT involved in the process to make sure we had everything we needed from not only the vendor, but our own hospital IT department as well. If there were gaps we would work together to flesh them out.

    What happens if the IT department is given the leeway to make a decision for the pharmacy on which automation and/or technology they should use? They might make the “right decision”, but if they did it would be the result of sheer dumb luck. The selection process should be one that looks to find the best fit for the pharmacy, one that fits into the pharmacy’s distribution model, one that lines up with existing technology, one that takes future pharmacy plans into consideration, one that will help drive pharmacists out of the pharmacy toward more clinical activities,  one that acknowledges the strengths and weaknesses of the vendor in terms of functionality, usability and support,  and so on. The decision should not be based on who uses the best security protocol, or who prefers Dell Servers over HP Severs, or whether or not the vendor needs network access for support or not, and so on and so forth.

    I truly feel sorry for healthcare systems that ignore their pharmacy personnel when thinking about purchasing new automation and technology for pharmacy operations. In my opinion it’s a recipe for disaster. I certainly wouldn’t want to work in a pharmacy where the tools I used were selected by someone who didn’t even know what I was working on. The next time you have the oil changed in your car, ask the mechanic if he would let the person that installed their computers pick out his tools. I bet you’ll get a similar response to mine, although the language may be a bit more colorful. Better yet, ask a software engineer if he’d let a pharmacist pick out the hardware and software necessary to do his job. It’s a safe bet that he’d look at you like you’d lost your mind.

  • Interview with Healthcare IS [audio]

    I was recently interviewed by Healthcare IS. The audio interview is only about 20 minutes long and covers me answering some general questions about pharmacy informatics, my thoughts on working as an IT pharmacist, etc.

  • Saturday morning coffee [February 9 2013]

    MUG_ArizonaIt’s hard to believe that it’s February already.

    So much happens each and every week that 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….

    Last weekend I was on the road attending my daughter’s Power League volleyball tournament in Sacramento.  My brother Robert filled in for me admirably. I didn’t ask him to take up the reins, but I certainly appreciate him filling in the gap. Thanks, bro. Dig the mug by the way.

    I went through Phoenix, AZ twice this week while traveling for work, which made me think of the coffee mug to the right. It was once of four sent to me by Jason DeVillains last year. Jason is better known to many as The Cynical Pharmacist. Jason and I met via Twitter(@TheCynicalRPH) and have been chitchatting via the web ever since. Perhaps the next time I touch down in Phoenix I can lay over for a day and Jason and I can grab a cup o’ joe together. Jason also blogs over at The Cynical Pharmacist. Check it out.
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  • Crowdsourcing pharmacy: automation, technology, informatics

    redlegoI travel for work a couple of weeks a month, sometimes more, sometimes less. Most of the time I travel by myself, but recently I found myself traveling, albeit briefly, with another pharmacist. He and I ended up in a little pub one night talking about work; products, strategy, gripes, likes, and so on. Typical stuff when two guys get together and talk about work. After a while the conversation turned away from work and toward pharmacy in general. Just two guys talking about stuff that’s interesting.

    A few drinks and several bowls of popcorn later we had covered a lot of interesting pharmacy topics including acute care pharmacy operations, telepharmacy, medication therapy management, insurance company billing, specialty pharmacy practice and so on. There were several interesting ideas figurative sketched out on the back of a napkin that night. This type of comradery is good for the creative process as I’ve mentioned before.

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  • Adding Pharmacists to Primary Care Teams Increases Guideline-Concordant Antiplatelet Use in Patients with Type 2 Diabetes [article]

    Here’s an interesting little tid-bit in the January issue of The Annals of Pharmacotherapy. According to the article “adding pharmacists to primary care teams significantly and substantially increased the proportion of type 2 diabetic patients using guideline-concordant antiplatelet therapy“. Good stuff to be sure. Unfortunately the study only looked at the proportion of patients using antiplatelet therapy at 1-year after engaging the pharmacist. It would be interesting to see data around decreased morbidity, hospital readmission rates, etc to go along with the improved guideline-concordance.

    Abstract

    BACKGROUND: Antiplatelet therapy is recommended as part of a strategy to reduce the risk of cardiovascular events in patients with type 2 diabetes. However, compliance with these guideline-recommended therapies appears to be less than ideal.

    OBJECTIVE: To assess the effect of adding pharmacists to primary care teams on initiation of guideline-concordant antiplatelet therapy in type 2 diabetic patients.

    METHODS: Prespecified secondary analysis of randomized trial data. In the main study, the pharmacist intervention included a complete medication history, limited physical examination, provision of guideline-concordant recommendations to the physician to optimize drug therapy, and 1-year follow-up. Controls received usual care without pharmacist interactions. Patients with an indication for antiplatelet therapy, but not using an antiplatelet drug at randomization were included in this substudy. The primary outcome was the proportion of patients using an antiplatelet drug at 1 year.

    RESULTS: At randomization, 257 of 260 study patients had guideline-concordant indications for antiplatelet therapy, but less than half (121; 47%) were using an antiplatelet drug. Overall, 136 patients met inclusion criteria for the substudy (71 intervention and 65 controls): 60% were women, with mean (SD) age 58.0 (11.9) years, diabetes duration 5.3 (6.0) years, and hemoglobin A1c 7.6% (1.5). Sixteen (12%) had established cardiovascular disease at enrollment. At 1 year, 43 (61%) intervention patients and 15 (23%) controls were using an antiplatelet drug (38% absolute difference; number needed to treat, 3; relative increase, 2.6; 95% CI 1.5-4.7; p < 0.001). Of these 58 patients, 52 (90%) were using aspirin 81 mg daily.

    CONCLUSIONS: Adding pharmacists to primary care teams significantly and substantially increased the proportion of type 2 diabetic patients using guideline-concordant antiplatelet therapy.

  • fMRI study uncovers mechanism for drug cravings

    This article at Medical Xpress caught my interest because I’ve been reading Physics of the Future: How Science Will Shape Human Destiny and Our Daily Lives by the Year 2100 by Michio Kaku, which spends a fair amount of time talking about fMRI.

    “An fMRI machine uses “echoes” created by radio waves to peer inside living tissue. This allows us to pinpoint the location of the various signals, giving us spectacular 3-D images of inside the brain…

    The fMRI scans allows scientists to locate the presence of oxygen contained within hemoglobin in the blood. Since oxygenated hemoglobin contains the energy that fuels cell activity, detecting the flow of this oxygen allows one to trace the flow of thoughts in the brain.

    …fMRI scans can even detect the motion of thoughts in the living brain to a resolution of .1 millimeter, or smaller than the head of a pin, which corresponds to perhaps a few thousand neurons. An fMRI can thus give three-dimensional pictures of the energy flow inside the thinking brain to astonishing accuracy…”

    According to the Medical Xpress article:

    “Cues such as the sight of drugs can induce cravings and lead to drug-seeking behaviors and drug use. But cravings are also influenced by other factors, such as drug availability and self-control. To investigate the neural mechanisms involved in cue-induced cravings the researchers studied the brain activity of a group of 10 smokers, following exposure to cigarette cues under two different conditions of cigarette availability. In one experiment cigarettes were available immediately and in the other they were not. The researchers combined a technique called transcranial magnetic stimulation (TMS) with functional magnetic resonance imaging (fMRI).

    The results demonstrate that in smokers the orbitofrontal cortex (OFC) tracks the level of craving while the dorsolateral prefrontal cortex (DPFC) is responsible for integrating drug cues and drug availability. Moreover, the DPFC has the ability to suppress activity in the OFC when the cigarette is unavailable. When the DPFC was inactivated using TMS, both craving and craving-related signals in the OFC became independent of drug availability.”

    Cool stuff.

    Article referenced: Takuya Hayashi, Ji Hyun Ko, Antonio P. Strafella, Alain Dagher; “Dorsolateral prefrontal and orbitofrontal cortex interactions during self-control of cigarette craving.” PNAS, January 2013, DOI:10.1073/pnas.1212185110

  • Saturday morning coffee [January 26 2013]

    Amsterdam Coffee MugSo much happens each and every week that 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 coffee mug to the right comes straight from Amsterdam. I stopped there back in November 2011 on my way to Germany on a work trip. It’s a dirty city with a weird vibe to it. Everyone smokes and you better watch your butt or you’re likely to get run down by a bicycle, which appears to be a popular form of transportation. I walked through the Red Light District just to say that I’ve seen it. It was disturbing and depressing. It’s sad to see that kind of thing in my opinion.  Overall I didn’t like Amsterdam. You can have it. By the way, that’s a pretty big coffee mug. It hold a lot of coffee.
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  • Accuracy of preparation of i.v. medication syringes for anesthesiology [article]

    Here’s an interesting article from the January issue of AJHP that talks about the accuracy of medication syringes used in surgical procedures. Some of the findings are a bit unnerving: “18% of preparations deviated from the declared dose by ±20%, 8% deviated by ±50%, and 4% deviated by ±100%“. Humans, we’re just not all that good at things like this.

    Accuracy of preparation of i.v. medication syringes for anesthesiology
    Cyril Stucki, Anna-Maria Sautter, Adriana Wolff, Sandrine Fleury-Souverain and Pascal Bonnabry

    Abstract

    Purpose: The results of a study of the accuracy of i.v. medication preparation by anesthesiologists are presented.

    Methods: The accuracy of syringe preparation was assessed by analyzing the contents of 500 unused syringes collected after adult and pediatric surgery procedures. The collected syringes contained various i.v. medication formulations representative of different preparation techniques: atracurium 1, 2.5, and 5 μg/mL and fentanyl 10, 20, 25, and 50 μg/mL, which required serial dilution after withdrawal of the drugs from ampuls; thiopental 5, 25, and 50 mg/mL, prepared by diluting reconstituted powdered drug from vials; and lidocaine 10-mg/mL solution, which was withdrawn directly from the ampul into a syringe. Variances between actual and labeled drug concentrations were determined via a validated ultraviolet–visible light spectro-photometry method.

    Results: Overall, 29% of the evaluated syringes were found to contain drug concentrations outside the designated range of acceptability (±10% of the targeted concentration); 18% of preparations deviated from the declared dose by ±20%, 8% deviated by ±50%, and 4% deviated by ±100%. In one instance, the actual drug concentration was at variance with the labeled concentration by >100%. In 4% of cases ( n = 20), discrepancies exceeded 100%, suggesting not just imprecision but errors in the preparation process, such as incorrect dilution calculations and selection of the wrong medication vial by the syringe preparer.

    Conclusion: Analysis of different i.v. formulations of four medications prepared in syringes by anesthesiologists revealed a high rate of discrepancies between ordered and actual drug concentrations, suggesting a need for increased institutional efforts to prevent errors during the preparation process.

    Am J Health-Syst Pharm. 2013; 70:137–42