I finally got around to digging into the article on bar code medication administration (BCMA) in the most recent issue of the NEJM. It’s and interesting article that has already receiving a lot of press. It will probably be tossed around for months.
One thing I found amusing in the article was figure 1 on page 1706 (bottom image). I’ve had a similar visual on one of my office whiteboards (top image) for nearly a year. I like being on the same page with intelligent people.
A recent post by John Poikonen got me thinking about medication errors. They’re part of every pharmacists day, but we rarely give them much thought.
I’ve been a pharmacist for more than 10 years now and I’ve make my fair share of mistakes. I would like to think that none of those errors caused harm, but that would be naïve to say the least. And forget about the errors that were never detected because one can only speculate about those.
(more…)
I’m not a big fan of the using the “best of†model for hospital information systems (HIS). You know, when you buy the best pharmacy system you can find, and the best lab system you can find, and the best ED system you can find, and so on. All this does is create a giant headache for everyone involved because the systems don’t always play nice with each other, which means data gets lost or hijacked between systems by the Interface Noid. Data gets pushed, moved, shuffled, altered, chopped and converted, and it doesn’t always come out the way you intended. Or worse yet, you have a case where the systems aren’t interfaced at all.
I recently heard of a case where a hospitals ED system wasn’t interfaced with the rest of the facilities information systems and disastrous results ensued. A patient came in through the ED with a very specific allergy; noted in the ED system. The information wasn’t available in the nursing or pharmacy systems. The patient was admitted and transferred to the floor. The little detail about the allergy wasn’t passed on during report and the patient ended up receiving that very medication based on the attending physician’s order. To make a long story short, the patient had an anaphylactic reaction and won a three day, all expenses paid trip to the hospitals intensive care unit.
I wonder how often things like this happen due to short sided HIS implementation and deployment. Technology might not be the answer to all our problems in healthcare, but you have to admit it certainly could have helped in this particular example.
I’ve had a couple of eye opening conversations over the last week that have me concerned about the thought process surrounding pharmacy technology, where we’re going with it and what it’s supposed to do for us.
Rule #1: “That’s what the computer told me to do†simply isn’t justification for doing something that makes no sense. Computers are dumb. They do what we tell them, albeit very well, but they don’t think independently from the human operating them. It’s ok to question the decision made by technology if it doesn’t make sense clinically or logically. Drug errors occur for many reasons. And as humans we make mistakes and healthcare professionals are not exempt. Technology can be used as an additional barrier between a potential mistake and the patient; however pharmacists and nurses should not decrease their vigilance at any point in the medication distribution and administration process secondary to new technology.
Rule #2: technology implementation should not complicate your process. A complicated process is one that is destined to lead to frustration and create opportunities for mistake. Take advantage of technology to streamline a process. Create a better workflow, not a more cumbersome one.
I think the two things mentioned above are simple common sense, but somehow they get overlooked all the time. Just a thought.
From Implementation Science 2009 Sep 25;4:62:
Abstract:
BACKGROUND: Health information technology and electronic medical records (EMRs) are potentially powerful systems-based interventions to facilitate diagnosis and treatment because they ensure the delivery of key new findings and other health related information to the practitioner. However, effective communication involves more than just information transfer; despite a state of the art EMR system, communication breakdowns can still occur. 123 In this project, we will adapt a model developed by the Systems Engineering Initiative for Patient Safety (SEIPS) to understand and improve the relationship between work systems and processes of care involved with electronic communication in EMRs. We plan to study three communication activities in the Veterans Health Administration’s (VA) EMR: electronic communication of abnormal imaging and laboratory test results via automated notifications (i.e., alerts); electronic referral requests; and provider-to-pharmacy communication via computerized provider order entry (CPOE). AIM: Our specific aim is to propose a protocol to evaluate the systems and processes affecting outcomes of electronic communication in the computerized patient record system (related to diagnostic test results, electronic referral requests, and CPOE prescriptions) using a human factors engineering approach, and hence guide the development of interventions for work system redesign. DESIGN: This research will consist of multiple qualitative methods of task analysis to identify potential sources of error related to diagnostic test result alerts, electronic referral requests, and CPOE; this will be followed by a series of focus groups to identify barriers, facilitators, and suggestions for improving the electronic communication system. Transcripts from all task analyses and focus groups will be analyzed using methods adapted from grounded theory and content analysis.
Although the information in the article is only a design concept, it is still worth reading. Concepts like these could be useful for many outpatient as well as many inpatient alerts; labs that are outside normal parameters, results from blood tests, incorrect antibiotic choice following culture results, etc. With the advances in mobile technology, especially mobile communication devices, this is worth serious consideration.
Medication reconciliation is defined by JCAHO as “the process of comparing a patient’s medication orders to all of the medications that the patient has been taking. This reconciliation is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions.†The process should be fairly straight forward, but it is actually very difficult and time consuming.
(more…)
Thanks for all the people who ventured a guess. Only the medications are transcribed and the original image is posted below the answers as a reference.
(more…)
There is a nice article in the November 2009 issue of Hospital Pharmacy on the use of clinical surveillance in pharmacy. I’ve mentioned these types of systems before here and here.
From the article:
Clinical surveillance tools are atype of clinical decision support system (CDSS), providing pharmacists with patient information that has been filtered according to predefined criteria and is presented at appropriate times to enhance patient care. These tools pull data from 3 sources—admission/discharge/transfer (ADT), laboratory, and pharmacy—and use clinical rules to analyze the data and alert the user of instances that meet the rules’criteria. Though there is some variability in methods across the different vendors’ products, these Webbased applications enerally function by interfacing (HL7) with the hospital’s information systems to securely pull the data to the vendor’s server where the data are analyzed against a set of clinical rules. Some vendors allow the client to build their own rules, some provide a foundational set of rules, and others do not allow user-defined rules. This is an important distinction to make when evaluating the different applications.
For more information try visiting John’s Evernote repository for Clinical Decision Support.
Below is an example of some pretty bad handwriting. Take a look at it and see if you can decipher what the physician wants. I am looking for only medication related orders. Leave your guesses in the comment section. Good luck.
The solution can be found here.
Entering and making pediatric drips for pharmacists working in an adult hospital can be a real sphincter tightener. Pharmacists that aren’t accustomed to working with pediatric patients feel a little bit uneasy when an order shows up for a customized dopamine, dobutamine, etc. I remember working in a pediatric facility where we did this kind of thing all the time and no one gave it a second thought. We used a combination of two standardized concentrations, hi and low, for each commonly ordered drip. For code blue situations we often used the “Rule of 6’sâ€, which is now discouraged by the Joint Commission.
(more…)