Jerry Fahrni

Author: Jerry Fahrni

  • Fatal overdose of KCL caused by poor handwriting, lack of diligence

    imageISMP Medication Safety Alert: “A nursing home resident died from cardiac arrest after receiving a 10-fold overdose of oral potassium chloride because an order for 8 mEq was misinterpreted by several facility staff members as 80 mEq.” – A poorly handwritten order was a contributing factor to the error. What’s really scary about this error is that an 80 mEq dose of KCL is big, but not unheard of. I’ve entered orders for 80 mEq of oral potassium, however never for a nursing home patient. According to the ISMP Alert “[t]he pharmacist dispensing this medication to the nursing home recognized this was an "unusually high dose" but confirmed it was "correct" by calling the nursing home and speaking with one of the nurses.”

    Some simple things that could have prevented this error include some type of CPOE system, a healthy dose of clinical decision support software and pharmacy access to laboratory data. Any one of these could have made the difference.

    One other thing worth mentioning. Orders for oral KCL greater that 40 mEq per dose are typically accompanied by instructions for a set number of doses, i.e. 80 mEq po daily x2 doses for hypokalemia. It’s a simple thing, but could be the difference between electrolyte correction and death. In this particular instance the patient received the dose for 8 days before succumbing to hyperkalemia. 

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    image taken from ISMP Medication Safety Alert, Nov. 3, 2011, Vol 16, Issue 22

  • Portable storage media, the scourge of patient privacy

    LA Times: “Altogether, 16,288 patients’ information was taken from the home of a physician whose house was burglarized on Sept. 6, according to the UCLA Health System.

    The data were on the physician’s external hard drive, officials said. Though the hard drive was encrypted, a piece of paper with the password was nearby and is also missing. The physician notified UCLA the next day and officials began identifying patients affected.”

    I am continuously amazed at the number of security breaches involving patient healthcare information caused by careless use of portable storage media like external hard drives, flash drives, and even laptop hard drives. Patient information should never be stored or transported this way. I believe that utilizing cloud computing with simple browser access is a much better solution. 

    What makes this particular incident so bad is the cause; reckless behavior by a physician. This wasn’t UCLA’s fault, per se. Sure, the medical center must accept a share of the responsibility, the lion’s share of the blame falls in the lap of the physician. Not only did the physician have sensitive patient information on an external hard drive, but was dumb enough to have the password to access the drive on a piece of paper next to it. Kind of defeats the purpose of encryption and passwords, doesn’t it.

    For an eye-opening look at the magnitude of data loss and security breaches drop by DataLossDB.org sometime. It’s scary stuff.

  • The joy of being a cartoon pharmacist

    Pharmacists don’t exactly come to mind when you think of notable characters on TV. That’s why I felt compelled to post the short transcript below. It comes from Mort Goldman, owner of Goldman’s Pharmacy on the Family Guy cartoon series as he stands in front of a school class discussing his job as a pharmacist. It’s pretty funny. I tried to find a video clip, but couldn’t. In this case the written word doesn’t do it justice.

    Mort: On the whole, I enjoy my job as a pharmacist. In fact, many of my customers are your mommies and daddies. Jimmy Hopkins, your mother had awful postpartum depression after you were born. And Danielle, your father had bad, very bad hemorrhoids that stung him unmerciful. Oh, they were awful. They were like stinky little balloons. And I gave him some special ointment and he hurt so bad that he had to apply it in the car with his sock. Thank you.

    Boy: Cool! I want to be a pharmacist!

    Boy 2: Oh, yeah!

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    Family Guy Episode: Mr. Saturday Knight - Aired on Tuesday, Jun 08, 2010

  • New Windows 7 slates on the way

    Hmm, it looks like we’re going to start seeing more and more Windows 7 slates as the end of the year approaches. The most recent sighting is the the Dell Latitude ST.

    According to Tablets Planet the “Latitude ST tablet features a Intel Atom processor, Windows 7, Microsoft Bitlocker, Kensington lock, USB port, SD card slot, HDMI port, and a LCD that features finger multi-touch and a stylus for input, and there are also front and rear-facing cameras for video conferencing (front) and taking photos (rear).”

    In addition the Latitude ST claims an 8 hour battery life. This is in line with the battery life claims of the Samsung Series 7 tablet.

    Now if I could just get Samsung or Dell to develop a docking solution similar to the Asus Transformer we’d have something.

  • Accurate Assessment of Adherence (man vs. machine) [abstract]

    A recent article in Chest1 demonstrates the value of electronic data collection in medication adherence. In this case it was inhalation therapy in cystic fibrosis patients. This type of article is important as we consider the future of electronic health records and where the data for such records should come. Remember, people are notoriously unreliable historians while computers don’t lie.

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  • Hmm, retail pharmacy still sucks? Go figure

    Jim Plagakis:

    The rules of the game as they are designed by CVS and Rite-Aid make the game unwinnable unless you are going to operate as a glorified technician.  It must be downright painful for pharmacists with high personal standards and respect for professional ethics.  I can understand the bitterness.  I can understand the feelings of despair.  I can see the anger.  Just don’t forget:

    It’s the JOB, Stupid.  There is nothing wrong with the PROFESSION.

    Jim’s post rings home for many pharmacists that live in the retail world. Not the community pharmacy world, which is entirely different, but the retail world.

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  • The future of tablets, operating systems and innovation

    TeachPaperless: A Prediction: What Platform Will Be Running on the Tablets in Your Classes?

    Windows.

    That’s my prediction. Here’s my rationale: Windows 8 has been designed especially for touchscreen computing. Windows is the overwhelming winner in the enterprise market. Major PC manufacturers from HP to Dell are re-evaluating their business in a post-iPad world. In the short term, no PC company is going to catch up to the iPad. And the Kindle Fire will soak up much of the remaining consumer market for folks who just want to watch movies and read books on a tablet.

    Although this article is aimed at the future of tablets in the classroom, it has deeper undertones. The author predicts that Windows will rule the day, but also states that "in many ways it’s a ludicrous prediction". I don’t think it’s ludicrous at all. Over the past 12-18 months I’ve attempted to replace my Win 7 tablet PC with an iPad, an Android tablet and an HP TouchPad. They serve a purpose, but none of them have come close to allowing me to leave my laptop or Win 7 tablet at home.

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  • Interactive Handbook on Injectable Drugs for iPad and iPhone

    It feels like a day doesn’t go by that I don’t receive an email letting me know of something cool for mobile devices. With the ever increasing onslaught of tablet and smartphone use in pharmacy practice it’s only a matter of time before everything will be available in some electronic media format.

    In this case it’s ASHP’s Interactive Handbook on Injectable Drugs: IV Decision Support by Lawrence A. Trissel. Every pharmacist working in a hospital pharmacy knows about this reference. And if they don’t then they have a big problem because it’s only one of the most definitive reference sources for IV compatibility. Over the course of my career it’s simply been know as “the Trissel’s”. (kind of like “the Talyst”…just sayin’ – private joke people)

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  • Tarascon Pharmacopoeia available for Android and iPad

    I received the email below a few days ago announcing that The Tarascon Pharmacopoeia is now available for Android and the iPad. I’m not a big fan myself, but the reference appears to be popular with certain crowds. Historically it’s more popular with community/retail pharmacists than hospital pharmacists. This might have something to do with the availability of drug pricing in the Tarascon Pharmacopoeia. Who knows.

    Link to Android version is here.

    Link to iPad version in iTues store is here.

    tarascon

  • Cool Football Technology

    technology review:

    Dan Garza, assistant professor of orthopaedic surgery at the Stanford School of Medicine, and his team recently completed a study of the mouth guards using crash-test dummies, and  plan to publish the data soon…

    Garza believes that the mouth guards may turn out to be more accurate than helmets because they don’t shift as much during impact. They also read forces inside the skull more closely, and they’re cheaper…. The Stanford studies will collect data from the mouthpieces as well as video of plays, when available, and clinical information about players’ injuries. 

    Seriously, how cool is that. Leave it to Stanford – yes that wonderful school just up the road from where I live – to make science fun. How can you go wrong applying science to football?

    You can read more about impact sensing mouthguards at the X2IMPACT website here.