Medicine 2.0 Congress blogspot : “Readability of the Top 50 Prescribed Drugs in Wikipedia – Devin explained that a sample of 50 most prescribed drug in United State were selected and the content related to those prescribed drugs in Wikipedia were indentified and saved as HTML files for evaluation. Each Wikipedia entry was analyzed independently by two investigators using Flesch-Kincaid Grade Level. A Health information readability analyzer was also used to integrate dimensions that other readability tools lacked such as : lexical, the most easy to read; semantic, the most difficult to read; cohesion and syntactic. Eventually, descriptive statistics was used to analyze the scores generated by these tools. Devin concluded by stating that the reading level of the 50 prescribed drug entries in Wikipedia are higher that the reading level of consumers. Therefore, there is a potential barrier of health and drug information for some Wikipedia users. To improve the Wikipedia, the vocabulary can be simplified; and in order to improve the consumers’ comprehension, the lexical and syntactic constructs need to be enhanced without compromising cohesion and structure.†– Similar to information provided by drug reps, Wikipedia is not a credible drug reference and should never be used as such. While interesting, Wikipedia may contain opinions and information presented in a biased manner. The fact that there is a study on the usability of drug information in Wikipedia is disturbing. When looking for drug information, healthcare professionals should always use credible references like Lexi-Comp, UpToDate, MD Consult, or something similar. If detailed information is needed, consult the primary literature. Consumers should consult their local pharmacist for credible drug information.
Category: Medication Safety
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When does medication safety become counterproductive?
Being a pharmacist I’m exposed to lots of procedural changes implemented in the name of patient safety. Tall man lettering, black box warnings, pop-up warnings for allergies, drug interactions, pregnancy indicators, lactation indicators, “high risk drugs listsâ€, shiny labels to identify sound-alike-look-alike-drugs (SALAD), separation of stock for similarly named medications, bar coding, double checking, triple checking, and so on and so forth ad infinitum. As the “IT Pharmacist†I get to see all these changes up close and personal because I’m often involved in their implementation in one way or another. Do we actually have any evidence to support using all these things?
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Infusion catheter delivers medication with precision
Vascular Designs’ IsoFlowâ„¢ infusion catheter … is a dual balloon catheter designed for controlled and selective infusion of physician-specified fluids into selected vasculature by means of temporary occlusion of a target region of the vessel with simultaneous perfusion of blood past the isolated region. With this type of directed approach to fluid delivery, you can increase drug concentrations at targeted sites while reducing systemic exposure, thereby improving efficacy and patient outcomes. This makes IsoFlow ideal for battling diseases such as cancer for which treatment requires the direct infusion of chemotherapy drugs to a targeted region of the body like a tumor.
The IsoFlow catheter enables sideways perfusion, The IsoFlow catheter enables sideways perfusion, which gives you the ability to push specified fluids both into side branch and angiogenicly formed vessels, letting medications reach an isolated area in a highly targeted and concentrated fashion. With IsoFlow’s unique design, fluids can reach areas that could not previously be treated directly.
How cool is that.
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An infusion pump that can be used around MRI scanners…Cool!
The MRidium 3860+ from IRadimed is the first non-magnetic iv pump with integrated SpO2 monitoring designed specifically for use around MRI scanners. According to the manufacturer: “The new 3860+ offers significantly upgraded performance and features to the already proven MRidium MR IV pump product line. With the addition of a 10 key numeric input keypad and its wider pumping range of O.l mL/Hr to 1400 ml/Hr, the 3860+ series allows quick programming and broad fluid flow control. The drug library has been enhanced to allow user profiles to be stored and easily transferred via the SD memory card to other pumps. With the addition of the Masimo SET Sp02 monitoring and specialized fiber optic sensor, the 3860+ facilitates both safe sedation AND monitoring in one portable MR safe unit. Approved for use in 0.2 to 3 T Magnets. Features: Dose Rate Calculator, Bolus Dose Programming, Secondary Drug Delivery, Syringe Delivery, Adjustable Occlusion Pressure, KVO, SpO2 monitoring, and Alarm Settings, [and] CQI Data Ability w/Tracking Software which records up to 3000 Entries.†A couple of things that stand out, besides being able to use it around an MRI scanner, are the wide range of infusion rates and the ability to use standard 10 to 60 mL syringes with the MRidium Syringe Adapter IV Set (image shown). I’ve seen several pumps that limit users to 999 mL/hr, which can create an issue in certain circumstances. The ability to utilize syringes comes in handy for pediatrics; most pediatric infusions require an entirely different pump.Pharmacists aren’t typically interested in infusion pumps, but they catch my eye from time to time since my involvement with the Alaris Smart Pump project at our facility.
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Verbal orders won’t necessarily go away after CPOE implementation
AMN Healthcare: “A new AHRQ-funded study found that of roughly 973,000 orders that physicians at a large, Midwestern hospital gave nurses over a 12-month period, roughly 20 percent were verbal orders. The hospital transitioned from a paper-based to computerized provider order entry (CPOE) system during the study period. The new study is one of the first to examine how the content of verbal orders or the context in which they are given might increase risk of error. Although more hospitals are converting totally or in part to CPOE, most experts expect verbal medical ordering to continue to be used extensively for the foreseeable future. According to the researchers, who were led by the University of Missouri’s Douglas S. Wakefield, Ph.D., five factors potentially contribute to verbal orders causing medical errors—type of care setting; time of day or week; type of communication and related variables, such as the physician’s and/or nurse’s accent and articulation; the providers’ knowledge of the patients for whom the order is being given and previous contact experience between the physician and nurse; and environment including background noise and staffing levels. The study, “An Exploratory Study Measuring Verbal Order Content and Context,†was published in the April 2009 issue of Quality and Safety in Health Care.†“– There really are very few excuses for giving verbal orders in a facility that utilizes CPOE. A couple that come to mind might be in a true emergency or in the case of a physician being unable to get to a computer. Unfortunately physicians frequently abuse the verbal order system out of laziness, creating a dangerous situation. I’ve had to clarify my fair share of verbal orders that were poorly transcribed from the physicians lips, to the nurses mind, and finally onto paper. There are simply too many variable during the process. It’s like the old game where you start a rumor with one person and have them pass it on to someone else and so on down the line. At the end of the line, you have a garbled mess. Verbal orders are like that. CPOE is implemented as a safety feature to reduce prescribing and transcription error, but to benefit from the feature physicians have to use it.
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Medicated patch slips into wrong ADC pocket
Hospital Pharmacy: “During the process of with drawing a patient’s nicotine patch from an automated dispensing cabinet (ADC), a carousel pocket opened to reveal 2 nicotine patches and 1 fentaNYL 50 mcg/hr patch. The nurse using the ADC immediately called the pharmacy to report the discrepancy. The pharmacy investigated and found that it was not a dispensing error. Both patches (nicotine and fentaNYL) were stored in the same medication carousel, and the fentaNYL patch slipped over the top of one pocket and into another pocket that contained nicotine patches. Generally, the hospital reserved ADC carousel pockets for controlled substances, but there was a history of pilferage of the nicotine patches when stored in matrix drawers. To deter pilferage, the pharmacy began stocking them in secure carousel pockets with the tracking feature on to count the product. FentaNYL was in a nearby pocket by itself, but when the carousel turned, patches sticking up from the fentaNYL pocket were caught and dragged to another pocket that housed nicotine patches.” - This type of occurrence is more common than you might think. To prevent this type of thing from happening, many hospitals will utilize a system similar to the Pyxis CUBIE system. Pyxis CUBIE pockets are small containers with a clear plastic lid. The lid remains closed until that medication is accessed via the Pyxis medication terminal. This prevents items from jumping to another location.
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Deaths caused by postoperative hydration
ASHP: “ Standards Needed for Postoperative Hydration Therapy, ISMP Says – BETHESDA, MD 13 August 2009—Investigations into the deaths of two six-year-old children have prompted the Institute for Safe Medication Practices (ISMP) to call for the establishment of standards of practice for i.v. hydration therapy in postoperative patients.
According to today’s issue of ISMP Medication Safety Alert!, a six-year-old girl who underwent tonsillectomy and adenoidectomy died after receiving 5% dextrose in water at 200 mL/hr for 12 hours. The postoperative orders had stated “1000 cc D5W – 600 cc q8h,” but the pharmacist entered an incorrect infusion rate into the electronic medication administration record. This error was not noticed until a pediatrician, consulted by the surgeon because the girl had a grand mal seizure, recognized that the patient had signs of hyponatremia and water intoxication. The patient had had seizure-like activity earlier in the day, but the surgeon, contacted by telephone, attributed those episodes to a reaction to promethazine even though the nurses had expressed doubt.
In the other case, according to ISMP, a six-year-old boy who underwent surgery to correct a malformation in his aorta died after nurses dismissed his parents’ concerns about their son becoming increasingly less responsive on the second postoperative day. The physician had prescribed an infusion of a sodium chloride solution because the boy’s serum sodium concentration had dropped subsequent to treatment with diuretics. No sodium chloride infusion was documented in the medication administration record, however. The nurses attributed signs of hyponatremia to the patient receiving hydromorphone for pain relief and being “fidgety” from pain.â€
Hyponatremia is basically the result of excess water (case #1 above) relative to sodium and is one of the most common electrolyte abnormalities in hospitalized patients. The condition can cause significant morbidity and mortality. Unfortunately incorrectly treating the condition can be dangerous as well (case #2 above).
Signs and symptoms of hyponatremia are directly related to the central nervous system and include anorexia, nausea, lethargy, headache, apathy and muscle cramps. In severe cases, symptoms worsen and can advance to seizures, brain damage, and even death secondary to cerebral edema.
Treatment of hyponatremia can be quite controversial as aggressive replacement can lead to osmotic demyelination syndrome (i.e. central pontine myelinolysis); a painful and potentially deadly condition. Unfortunately the brain responds rapidly to a fall in plasma osmolality, but slowly to correction. Complete restoration of solutes in the brain may require up to 5 to 7 days. For this reason, aggressive sodium replacement should be limited to severe cases and patients should be closely monitored for several days following aggressive treatment for hyponatremia.
Tragedies like those mentioned above should, in theory, never occur. We continue to develop guidelines and technology to prevent such mistakes from ever happening, but will never be able to eliminate the “human factor†so blatantly described above. Our best hope is to create a system that decreases the occurrence of errors and minimizes damage when they occur.
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Apparently some pharmacists are worried about personal health records
Healthcare IT Consultant Blog: “Pharmacists’ representatives have claimed that use of private health record services such as Google Health and Microsoft HealthVault could risk fragmentation of electronic patient records. The Royal Pharmaceutical Society of Great Britain said “the proliferation of these systems and indiscriminate use†could lead to information on drug allergies, possible interactions, duplications or dose adjustments not being available when it was needed. The society, which was responding to a consultation by the Nuffield Council on Bioethics on medical profiling and online medicine, said there could be “serious patient safety implicationsâ€. It argued that the single health record supports the seamless transfer of care between primary and secondary settings and promoted multi- disciplinary working.” – I don’t necessarily agree with “the society” about personal health records. Personal health records – like medication lists carried in wallets, purses, and pockets – serve as additional information to an already detailed health system record. The technology is in its infancy and further growth and development should be encouraged. I believe it empowers the individual with enough control to become interested in their own care. I wouldn’t remove a patient allergy from the pharmacy system based solely on the information in a patient’s personal medical record, but would certainly investigate the opposite. First hand information directly from the patient is a valuable commodity. I remember interviewing patients upon admission to Long/Moffit Hospital on the UCSF campus when I was a 4th year pharmacy student. Many times asking the right questions led to the patient remembering something they had forgotten. If that information would have been in a digital personal medical record, the patient’s lack of memory becomes a non-issue. UCSF had the luxury of 30 pharmacy students running around talking to patients. Most hospitals aren’t so lucky.
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UCSF launches prescription help
The Business Journal: “The UCSF School of Pharmacy has launched a new service in Fresno to address the urgent need among Central Valley residents and their health care providers for assistance in managing their prescriptions. The service will start scheduling appointments this week and will officially open for in-person patient consultations on Sept. 1. Through the program, patients will meet one-on-one with an experienced clinical pharmacist to evaluate the prescriptions they currently use, ensure the medications are safe and effective for them, and help them manage their daily drug regimens.” – This is a great service and people should take advantage of it. I’ve reviewed the medication regimens of several members of my own family and you would be shocked to learn what I’ve discovered. My review of family medication regimens have revealed a duplicate therapy, a significant drug interactions, one medication causing side effects that were being treated as a medical condition, a medication being used for the wrong condition and one medication that was never prescribed; it was accidentally added to the patient’s profile by mistake in the pharmacy. I recommend that all pharmacists review the medication regimens for all their family members. If you find something weird, I’d love to hear about it.
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New drug education
Medicine And Technology: “We have seen so many new drugs and even new classes of drugs emerge over the last ten years. How do most physicians learn about new drugs? Many (certainly not all) community practitioners would say they learn what they need to know from the drug reps. Others indicate continuing medical education or CME activities as their main source of information regarding new drugs. Back in the “old days,” docs would also attend many promotional/marketing dinners and social functions to learn about new medications. Those days are ending as PhRMA code regulations get stricter. So what is the most effective way for physicians to learn about new drugs? They are so busy and easily overwhelmed by their workload that many have a difficult time keeping up with the latest science, the latest medical news, or even urgent FDA alerts and warnings.” – Any healthcare practitioner should be leery of using “drug-reps†or marketing dinners to educate themselves about new drug therapy. Remember, drug-reps are in it for the sales. In most cases they are not even healthcare professionals; pharmacist, nurse, physician. There are few truly unique breakthroughs in drug therapy each year and even fewer turn out to live up to expectations. Several years may be necessary to properly evaluate a medication’s place in therapy. I never understood the bandwagon approach to medication therapy, it’s irresponsible. Information on new drug therapy should come from primary literature or other reputable sources, such as the Pharmacist Letter, the Medical Letter, or from practice guidelines developed by professional organizations like the Infectious Disease Society of America (IDSA) and the American College of Chest Physicians (ACCP). Heck, this would be a good place to start reducing the cost of healthcare as many new “me too†medications with no proven benefit are often significantly more costly than their evidence-based counterpart. Why isn’t anyone talking about that?