Jerry Fahrni

Blog

  • Has adoption of IV Workflow Management Systems in hospital pharmacies slowed?

    Pharmacy Purchasing & Products (PP&P) puts out a survey each year called The State of Pharmacy Automation (SOPA). The 2017 PP&P SOPA is out and available for your reading pleasure.

    The PP&P SOPA survey covers many automation, technology, and practice trends. One item that I look at each year with great interest is the reported IV workflow management system (IVWFMS) adoption rate. I’ve written about IVWFMS many times. I even went as far as to do a podcast dedicated to them back in 2015.*

    While reviewing the 2017 SOPA numbers, I was surprised to see that this year’s survey shows no gain in adoption of IVWMS over last year. They appear to be stalled at approximately 19%, same as last year (see graph from PP&P 2017 SOPA below).

    While informative, it’s important to take these survey results with a grain of salt. Response rates are incredibly low, for one thing. Results can also be skewed based on participants, i.e. it may not be the same pharmacies responding year over year. This makes it difficult to draw direct comparisons from one year to the next. 

    Regardless, I was still surprised to see the flattened curve. I expected to see a sharp uptake. Most facilities I go into these days are using, or in the process of implementing, an IVWFMS of some kind. It’s becoming less common to find a facility not using one of these systems, especially in larger facilities where they seem to be slowly becoming best practice.  

    One other item worth mentioning is my belief that last year’s survey overestimated the number of facilities using IVWFMS. So if last year was really 12-15%, perhaps this year’s result is an improvement. That’s purely speculation on my part. I have nothing concrete to back it up other than my sense of the market. Through no fault of PP&P, I feel like these surveys are a poor representation of what’s really going on in the real world.

    Other takeaways from this year’s survey:

    • Larger hospitals are adopting IVWFMS faster than smaller hospitals. No surprise here. If you’re a hospital with more than 400 beds and you haven’t implemented one of these systems, you’re wrong and should be embarrassed by your lack of action. “Ninety-nine percent of the failures come from people who have the habit of making excuses.” ~ George Washington Carver. Simple as that.
    • DoseEdge by Baxter is the #1 system in use. Again, no surprise. This corresponds to what I see in the wild. Baxter has been in the game for a while. DoseEdge is definitely the first system that comes to mind when talking about IV room technology. Pharmacy Keeper by MedKeeper at #2 is a bit of a surprise. I have yet to go into a pharmacy that is using it. It’s a less functional system than say DoseEdge or BD Cato, but it’s also less expensive and easier to install, implement, and maintain. I personally believe pharmacies should be looking at systems with proven gravimetrics, but that’s just me. Pick your own poison.
    • DoseEdge by Baxter is the #1 system under consideration for new implementations. BD Cato comes in at #2 by a small margin. DoseEdge at #1 surprises me a bit. Most facilities I go into these days have BD Cato at the top of their list of possibles, and for good reason. BD Cato has a lot to offer, especially now that they are part of CareFusion. Perhaps the survey is a bit behind what I’m seeing out in the wild. Impossible to say.

    That’s it. I’m not sure that the raw numbers presented in the survey are helpful, but the information in the SOPA survey goes way beyond the numbers. For instance, the SOPA may introduce pharmacies to vendors and technologies that they’ve never heard of before. I encourage everyone to read through the PP&P 2017 SOPA. Who knows, you might find something new and exciting in there. I’ve been doing this for many years, but I still get surprised from time to time. 

    I can’t explain the SOPA survey results, but overall it feels to me that adoption of IVWFMS is still on the rise.

    —–

    *Looking back through some of my old posts — and the podcast — it’s amazing how little this landscape has changed.

  • Saturday morning coffee [September 2 2017]

    “Why do you look at the speck of sawdust in your brother’s eye and pay no attention to the plank in your own eye?” — Matthew 7:3 (NIV)

    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…

    The Hitman’s Bodyguard was #1 at the box office last weekend, making it two in a row. It’s a decent movie. Not as funny as one might think, or hope. My wife and I both thought the same thing, Ryan Reynolds playing Deadpool without the costume.

    Speaking of movies, this Summer hasn’t been kind to the Hollywood bottom line. From the New York Post: “Heading into the next-to-last weekend of the summer movie season, the US box office was running 13.4 percent below last summer, according to comScore.” Take it from someone that likes watching movies on the big screen, this summer has indeed been lackluster. The Mummy wasn’t very good. Transformers 5 was bad. Planet of the Apes was too dark and depressing. Atomic Blonde had some awesome fight scenes, but was otherwise meh. Dark Tower made me look at my watch and wonder “how long is this thing”. And the above mentioned Hitman’s Bodyguard was just ok. Wonder Woman was the cream of the crop, leaps and bounds better than any other movie this summer. It makes me desperate for Justice League.

    Lest we forget just how powerful Mother Nature can be, Houston, Tx is literally under water following Hurricane Harvey.

    Alabama is sitting pretty at #1 in this year’s first preseason Top 25. And there they will sit until someone knocks them off. I think it’s going to be a great year for college football. As for the NFL, not so much. I’ve lost almost all interest in the NFL. I haven’t watched a single pre-season quarter.

    The NSAS Flickr site has some pretty cool images from the eclipse.

    It appears that “banana bags” are no longer the treatment of choice for management of alcohol-associated vitamin and electrolyte deficiencies. Go figure. The practice of using banana bags has been called into question secondary to time to infuse, cost:benefit, etc. “Based on the published literature, for patients with a chronic alcohol use disorder admitted to the ICU with symptoms that may mimic or mask Wernicke’s encephalopathy, we suggest abandoning the banana bag [in favor of different therapy].” — Flannery A, Adkins D, Cook A. Unpeeling the Evidence for the Banana Bag. Critical Care Medicine. 2016;44(8):1545-1552. doi:10.1097/ccm.0000000000001659.

    Calcium Gluconate is the calcium salt of gluconic acid, an oxidation product of glucose. It’s commonly used in healthcare, even more so now that Calcium Chloride is hard to get. The 10% solution, pictured below, is supersaturated and stabilized by the addition of calcium saccharate tetrahydrate. The problem is that supersaturated solutions are prone to precipitation. I was basically unaware of the problem until I found this bottle. I Tweeted about it and received multiple responses indicating that “it happens all the time”. In my 20 years, I don’t recall ever seeing this before. Some propose that it’s the warm California weather that prevents it from happening. Maybe.

    In the wake of what went down in Charlottesville, some groups were kicked off the internet. For example, Cloudflare Inc., an internet security service, cut ties with the neo-Nazi website the Daily Stormer. While everyone seems to agree that these people are aholes, I think we’re getting into some pretty dangerous territory. Even Cloudflare’s CEO, Matthew Prince thinks so, and he’s the one who pulled the plug on Daily Stormer. According to Prince he “Literally… woke up in a bad mood and decided someone shouldn’t be allowed on the internet. No one should have that power”. He’s right, no one should have that power. Everyone believes in the right to free speech and having their own opinion until someone else’s opinion doesn’t agree with their own. At that point rational thought goes right out the window. Whether I disagree with Daily Stormer’s views is irrelevant. I have no idea what their views are. I’ve never been to their site. I am not a neo-Nazi nor do I believe in their cause, at all. Until the Charlottesville incident I had never even heard of them. However, that’s not the point. What if someone woke up one day and decided I shouldn’t be allowed on the internet because of my views? That’s some scary stuff right there. Think about it.

    There’s an interesting article at Ars Technica about the slippery slope we’re on with internet censorship.  

    Android Authority: “The official Android 8.0 release is here: Android Oreo officially arrived Monday August 21 during the solar eclipse. The over-the-air (OTA) update began rolling out immediately to supported Pixel and Nexus devices and factory images were posted on the Android Developers’ site the same day.” – Android 8.0 – Orea – will include the following new features: Picture-in-picture, Notification dots, simplified autofill framework to simplify how users set up a new device and synchronize passwords, system optimizations and background limits, auto-sizing textview, adaptive icons, shortcut pinning, and a few things under the hood that are over my head. My wife’s Pixel XL received the update a couple of days ago. I’m jealous. 

    The Essential Phone is finally available, sort of.  While I appreciate the engineering that went into the device — and it is beautiful — the reviews have all said the same thing, it’s a beautiful phone that’s not quite up to par in certain key areas.  Not to mention, the company has suffered from shipping problems and at least one email slip up. As much as I link new toys, there’s just nothing there to entice me.

    IFA 2017 is going on in Berlin as we speak. I love reading about all the cool stuff that shows up at IFA each and every year. In years where I’m thinking about buying a new laptop — like this year — I typically wait to see what drops at IFA before making a decision.

    The Samsung Note 8 was recently announced. My Note 5 was the best smartphone on the market when I bought it, and it still kicks butt. From what I’ve seen and read, the Note 8 is better in almost every way, with a couple of minor exceptions. It looks like Samsung has the best smartphone on the planet, again. For your reading pleasure: 10 Reasons you’ll love the Note 8. 

    Chrome Unboxed: Chrome Tip To Help Those Who Use Lots Of Tabs: “Take your files app, for instance: you can hold CTRL and select multiple items or hold SHIFT and select a range of items with just a couple clicks….That’s right, you can hold CTRL and select multiple tabs. After this, you can grab any of the selected tabs and move them around as a group. Likewise, if you click one tab, hold SHIFT, and then click another tab, all the tabs between are selected and can be moved as a group.” – I’m a longtime user of Chrome and had never heard of this tip before. Very useful. 

    Speaking of Chromebooks, I’m thinking about giving them another try. Even after my recent failure, I’m still drawn to them. This time around it’ll be either a Samsung Chromebook Plus or Asus Chromebook Flip C302, I think.The Samsung Chromebook Plus has the edge, but the stupid thing doesn’t have a backlit keyboard. Then again, I’ll wait until IFA is over before making any decisions. 

    I continue to be amazed by the quality of images captured by smartphones. The image below was taken with my two-year old Samsung Galaxy Note 5 while out walking my dogs. 

    Have a great weekend, everyone.

  • Ownership of healthcare data

    A couple of weeks ago my brother wrote a piece about access and ownership of medical records. My brother isn’t a healthcare professional but he is an intelligent, tech-savvy individual that has been forced to navigate the healthcare system due to his own plight as well as time spent helping with my mother’s care prior to her death following complications of a liver transplant. I have also written about this myself, albeit from a slightly different perspective.

    “Seriously though, why should our medical records be locked in a system we cannot access? We can learn something from Twitter, Facebook, and Google. We should own our medical records — via an open standard — and allow doctors and hospitals to ask our permission to see them. Much like friending someone on a social network. The doctor looks me up, asks if they can see my records, I get a message saying the doctor would like access to my records, and I choose to let them or not. My choice, my records.”

    Robert brings up an interesting concept. How one would go about creating such an open standard, and where that data would be stored are two things that have to be addressed. To be absolutely “neutral”, I suppose the U.S. government would have to handle both. That’s not comforting. Remember, the government created the DMV and IRS. Yikes!

    Allowing people to keep, store, and manage their own healthcare data is clearly not an option. There are those that would be quite good at it and those that would suck at it.

    I often consider banking when I think about healthcare data. Many of us (all?) use credit and ATM cards, ATM machines, banks, mobile pay, and so on daily. We never really think about our data, i.e. who has it, where it’s stored, how to access it, etc. However, when I need to look at something, the information is nearly always readily available and retrievable. Also, when I go to buy a car or home, finance something, etc. it always seems easy for those that need access to the information to get it. I don’t “own” my financial data, per se, but it’s always there for me and whoever else needs it.

    “Case in point. I have a problem with one of my knees. In 2004 I had surgery to remove cartilage, a bone spur, and some arthritis from that knee…Fast forward to 2017 and that knee has become an issue…I made an appointment with my family doctor to discuss the problem. Before going I tried to locate the doctor that did the surgery back in 2004, but she’s moved on. I contacted her old group to see if they had my records. Nope…I visit my doctor last week [and] explain there is a history here but I cannot tell her exactly what was done. My only explanation is I had surgery in 2004 to do X, Y, and Z. But I don’t know the exact terms nor do I know where the cartilage was removed or how much…She orders and x-ray and while she’s doing this she explains she’d like to do an MRI but the Insurance company requires she order an x-ray and order physical therapy before doing the MRI.”

    I had a similar experience a couple of years ago. I fell down my stairs at home — seriously, that happened — and ruptured my quadriceps tendon. I’ve never felt pain like that in my life. I thought I broke my leg. Anyway, I ended up in a local ED where I got x-rays, an ultrasound, and an MRI. Diagnosis: ruptured quadriceps tendon. Solution: surgery.

    Fast forward a couple of days later in the surgeon’s office. I had a copy of all my records from the ED visit on a CD. I thought I was being proactive. Not so. The surgeon’s computer and EHR system were not compatible with the data stored on the CD from the ED. The surgeon re-ordered two separate MRI’s. No kidding.

    My leg about a week after surgery.

    “This [the system] is broken”. Yep, there is no question that the system is broken. Just ask anyone that’s navigating it for the first time. Even my mother, who spent years in and out of hospitals secondary to her liver condition struggled to navigate the system at times.

    “…I know the EHR is only a tiny fraction of our dated system but I’d like to have a complete medical history. It’s my history…To fix this will take eons. Medicine is so far behind when it comes to technology. Look at systems like Epic. It is seen as a leader in its field, but it’s a closed system. How does that benefit anyone but Epic? It doesn’t….We need an Open API with services offered by many providers that are patient driven. Allow data to move between systems. Don’t make your money by holding patient data hostage. Make your money by building the better service.”

    My brother echos the sentiment of Ralph Waldo Emerson, “Make a better mousetrap, and the world will beat a path to your door.” I wish it worked that way in healthcare. But for some reason we continue to accept garbage. I am certainly not familiar with all EHR’s, but I have worked with several. They’re all terribly bloated and cumbersome. Not only that, they offer little in the way of cooperative information exchange. Sure, they all claim to play well with others, but my personal experience — along with that of many others — paints a different story.

    My brother and I don’t agree on much, but I think we’re on the same page here. We may not agree on which route to take, but we certainly have the same destination in mind. And that destination is better access to and sharing of healthcare data. 

  • Cool Technology in Pharmacy – Evolve Refrigeration

    The Evolve line of compressor-free, medical grade refrigerators* are quite impressive. Powered by SilverCore™ Technology, they have no compressor. And because they have no compressor, they have no mechanical parts, run quiet, use less electricity, and generate less heat.

    The system “absorbs heat energy from the storage cabinet using a non-toxic, non-hazardous refrigerant embedded in the walls. Heat energy is channeled up to a high-performance thermoelectric heat pump that cools the refrigerant and transfers the heat into the ambient environment“. Science!

    Evolve refrigerators meet CDC vaccine storage guidelines as well as requirements for use in a clean room. In addition, the units provide alerts for temperature, door, battery, memory, loss of WiFi, and loss of power via local and remote monitoring options.

    Because the refrigerators utilize solid-state technology, the company is able to squeeze more storage capacity into a unit compared to a similar sized non-solid state refrigerator. Up to 25% more storage capacity according to the company.

    I’m not sure if you’re aware of how much noise refrigerators can add to a pharmacy, but it’s lot. This is especially true in the IV room where PEC’s (hoods) already make the environment less than friendly to one’s ears.

    Not only does the Evolve line of refrigerators look pretty cool — no pun intended — their ability to reduce noise pollution in the pharmacy is a welcome bonus.

    ———–

    * I first wrote about Evolve back in December 2015 after seeing the product at ASHP Midyear.

     

  • Quick thoughts on Swisslog acquisition of Talyst

    I’m a little slow getting to my thoughts on this deal.

    A couple of weeks ago it was announced that Talyst had been acquired by Swisslog Healthcare. I’ve known about this acquisition for a while so I wasn’t surprised when it finally went through. Since the announcement, I’ve reached out to some friends and colleagues on both sides of the fence to get their thoughts and opinions on what’s in store for the future.

    My contacts at Talyst have been quite helpful and informative. Swisslog, not so much. In fact, they’ve provided me with no additional information or insight. All they’ve done is sic their marketing department on me, who in turn sent me a bunch of marketing hype that I can find online. Useless. I hope this isn’t a primer on what we can expect from the “new Talyst” moving forward. That would be unfortunate. I suppose this is the difference between a small company and a large company. I’ve always had trouble getting good information from large companies. There are simply too many layers to get through. With small companies, I can often go directly to the CEO. In large companies, I’m met by an army of people designed to keep people like me away from the CEO.

    Trying to figure out what Swisslog wants with Talyst has given me much to think about. Talyst is a market leader in certain acute care areas of pharmacy, such as carousels and inventory management software. They aren’t particularly creative or innovative, but rather steady. Talyst knows carousels but that market has kind of run its course unless you’re building a new pharmacy. The high-speed packaging market in acute care pharmacies is basically dead. The company doesn’t offer a competitive controlled-substance management system. They have a solid refrigeration strategy, but it’s not as innovative as something like Evolve. Talyst doesn’t do anything with RFID technology nor do they have a mobile strategy. Their software has good functionality but is antiquated in many ways. So what it is that Swisslog wants? Customer base? Name recognition?

    Swisslog doesn’t have much of a footprint in acute care pharmacies except for their tube system, which is basically everywhere. However, Swisslog is creative and innovative. They have some robotic systems like BoxPicker, PillPick, and RoboCourier. They make use of RFID technologies. They have pretty decent integration within their systems and they’re really good at logistics. Honestly, I don’t know as much about Swisslog as I do Talyst. 

    In general, I like products from both companies. However, it’s hard for me to imagine where Talyst products will fit into the Swisslog scheme. The items I think Swisslog needs from Talyst will likely be the most difficult to use, i.e. think square peg and round hole. I suppose the existing Talyst customer base is something that Swisslog can take advantage of. Customers using Talyst products could benefit from Swisslog products and better integration across the two platforms. That goes vice versa as well.

    Only time will tell, but I’m betting that we won’t see anything significant from this deal for quite some time.

  • Books in medicine, out of date and out of touch

    Nature Microbiology: “… I know it is a big deal in some fields to publish books and careers get decided by books. But for those of us working in medicine or public health, are books and book chapters worth the effort? Is the juice worth the squeeze?? … Based on my experience of contributing over a dozen book chapters, and serving as an Associate Editor of one textbook, my answer is no. I can give you half a dozen good reasons.”

    The author goes onto describe three specific concerns he has with book publishing in medicine:

    • Timeliness, or lack thereof. “A delay of 2 – 5 years might not matter in some fields (e.g. anthropology or history or statistical methods), but it matters in medicine and science!” You don’t say.
    • Affordability. Anyone that’s every purchased a science or healthcare related textbooks of any kind can attest to this. Some of my pharmacy school textbooks came with staggering price tags. Same thing applies to medical literature/journals. The subscription cost of some journals is criminal.
    • Access. No doubt a huge problem. “I also worry that those who really need my book can never get hold of it.” I find that this is also a huge issue with medical literature/journals. Getting ahold of articles isn’t easy. You can always get the information, as long as you’re willing to cough up the dough.

    The author is spot on with his assessment. This is especially true in my area of expertise, i.e. pharmacy automation and technology.  I’ve read the so-called pharmacy informatics textbooks. They’re out of date and expensive. I regret purchasing both of them.

    I suppose the big question after reading the piece in Nature Microbiology is how to solve the problem. I don’t have an answer. Going completely digital isn’t the solution, at least not with current technology. Hundreds (thousands?) of hours in front of a computer monitor has convinced me of that. It’s like gazing into a flashlight. Headaches and eyes that feel like sandpaper at the end of the day have led me to re-embrace paper. I know, I know, it feels antiquated to me as well. But I haven’t found a technology yet that completely replaces the ease and utility of using pen and paper for some things; reading literature and taking notes, for example.

    With that said, there are certain things that publishers can do to speed things up, improve access, and cut cost. The open-source literature movement has taught me that.

    Universities should also take a more active role in pushing publishers to do the right thing. It never ceases to amaze me when customers refuse to push back. I see this in hospitals with automation and technology vendors. Hospitals will purchase and continue to use technology that they are unhappy with. Why? Something akin to Stockholm Syndrome, perhaps.

    It will be interesting to see what publishers do moving forward. The current system is stuck in time, and as long as the end-user continues to accept the model, it will continue.

  • Ramping back up…

    Hello, old friend, it’s been a while.

    I have neglected this weblog. The reasons are not important. I continue to write, explore ideas, and think about technology. However, for the past several months I’ve been using a more traditional method to record my thoughts, i.e. pen and paper. There’s something cathartic about writing in a notebook, and I’ve filled a few.

    The world of pharmacy technology has, at least in my mind, become a bit stale. I’ve been exploring other technologies that I don’t routinely see in pharmacies, such as artificial intelligence and neural networks, augmented reality, nanotechnology, 3D printing (see some of this in healthcare), autonomous vehicles, and so on. This has allowed me to keep my sanity while continuing to work as a practicing pharmacist.

    I continue to explore pharmacy topics but in a more philosophical way. I’ve had many long discussions with pharmacists both young and old about the profession, past, present, and future. Some of the discussions have been enlightening and encouraging. Others have been disturbing and gut-wrenching. Overall, the profession is heading in a direction I don’t want to go. I’ve seen and heard things that lead me to believe that the profession as a whole is on life support.  If one were to gaze into the future and be truly honest with themselves, they would realize that pharmacy exists out of nostalgia more than necessity. But that’s of no importance here, at this moment.

    This weblog is a personal space, where I can write about pharmacy and other topics of interest to me. It was never intended to be used for business. I have to remember that. With that said, I think it might be time to revive my digital presence here. I have a lot of things to talk about. Some pharmacy related, some not. Some technology related, some not. Some uplifting, some discouraging. All interesting, at least to me.

    I’m thinking about a career move that would free up my weekends again. If that happens, perhaps we can even enjoy some Saturday Morning Coffee together. I miss my Saturday Morning Coffee.

  • Calling all students and professionals with an entrepreneurial spirit!

    Here’s something special happening in the local Fresno area….

    Calling all students and professionals with an entrepreneurial spirit! We’d like to invite you to join our new FREE HealthTech Initiative course. Find out more about this exciting class that will help develop healthcare products and services here: CHSU.ORG/HEALTHTECH-INITIATIVE

    We are looking for individuals to join teams with people from all types of disciplines including:

    • Health (Medical, Vet, Dental, Nursing, Pharmacy, …)
    • Computer Sci (Web/PC/Mobile app development, …)
    • Business (Entrepreneurship, marketing, pricing, …)
    • any individual interested in health care

    Class meets on Wednesday evenings from 5:30 pm to 7:30 pm at the California Health Sciences University (CHSU) in Clovis CA.

    • The class is FREE
    • The first class is August 23rd
    • The 15-week course ends on December 6th
    • Dinner is included

    Participants work in teams, and we will help you join a good team. You will not sit around for long-winded lectures. This course will provide participants with a “hands-on” introduction to leading an entrepreneurial enterprise by building a business model and constructing a prototype product or service. Participants work in teams, and all good ideas are acceptable.

    Teams will meet once a week to report progress. Teams demonstrate their prototype and business models to people or organization who are potential customers. Teams revise their prototypes and business models based on feedback. The step-by-step “Lean Startup” process is based on the National Institutes of Health (NIH) program to train medical scientists/entrepreneurs.

    Location: CHSU ANNEX BUILDING, ROOM 103-A, 45 N. CLOVIS AVENUE (NE CORNER OF SIERRA & CLOVIS), Clovis, CA 93612

    FOR MORE INFORMATION, CONTACT

    Dr. Charles Douglas at cdouglas@chsu.org or 559.573.8026.

    RSVP at: CHSU.ORG/HEALTHTECH-INITIATIVE

  • [Article] Evaluation of real-time data obtained from gravimetric preparation…

    I am currently reading an article on the use of gravimetrics in the preparation of hazardous CSPs published in the Journal of Clinical Pharmacy and Therapeutics.*

    The article addresses data collected from a large-scale, retrospective analysis of medication errors identified during the preparation of antineoplastic drugs, aka chemotherapy. The paper looks at 759 060 doses prepared in 10 pharmacy services in five European countries (Austria, Czech Republic, Denmark, Germany, and Switzerland) between July 2011 and October 2015. While the sheer number of CSPs made over that period of time isn’t impressive, the fact that they’re all chemotherapy is. I believe this is the first article of its kind. I can’t think of another article that looks at the use of an IV workflow management system across such a large number of facilities, much less the use of gravimetrics during the compounding of sterile hazardous drugs.

    The authors of the paper do a good job of: (1) addressing the use of gravimetrics versus image-assisted volumetrics, (2) covering the weaknesses of using syringes to measure small volumes (take a look at FIGURE 2 Tolerances of 1- and 5-mL syringes), and presenting a solid case for why gravimetrics is important for preparing hazardous CSPs. It also has some good images and tables, which I plan to refer to in future presentation.

    In a nutshell “[e]rrors were… identified during weighing stages of preparation of chemotherapy solutions which would not otherwise have been detected by conventional visual inspection“. I find that this is the key benefit of using a system with gravimetrics, i.e. the accuracy of the dose doesn’t rely on human inspection. Overall, the gravimetric system caught errors in 7.89% of the 759 060 antineoplastic doses prepared. This percentage is consistent with other studies looking at CSP error rates.

    A total of 13 831 errors for doses that deviated by more than 10% were caught by the system. That may not sound like a lot, but it can be, depending on the situation. Worse yet, 4 467 errors were off by 20% or more. Regardless of the situation, a 20% deviation in a dose is unacceptable. The significance, of course, is that a deviation this large could result in unintended toxicity or under treatment, depending on the direction of the error, i.e. 80% – 120% of the prescribed dose.

    The article concludes that the “Introduction of a gravimetric preparation system for antineoplastic agents detected and prevented dosing errors which would not have been recognized with traditional methods and could have resulted in toxicity or suboptimal therapeutic outcomes for patients undergoing anticancer treatment.” I agree in principle with the sentiment, but believe that the authors overstate the significance of the gravimetric system while understating the importance of secondary checks. By stating that the system “prevented dosing errors which would not have been recognized with traditional methods” they are assuming that all errors would have made it past a pharmacist or other secondary verification method. It’s possible — maybe even likely — that some of the errors would have made their way past a secondary check, but not all. In many cases, chemotherapy preparations go through several step-checks during the compounding process. Typically, one of those step-checks is verifying the dose — volume in the syringe — prior to injecting it into the final container. Errors are often discovered at this point in the process. With that said, the author’s overzealous conclusion shouldn’t take away from the importance of gravimetrics in preparing CSPs.

    Do yourself a favor and go get a copy of the article. It’s worth a few minutes of your time.

    The online article is here.

    A PDF copy can be downloaded here.

    ——

    Notes:

    The system used in all the pharmacies was BD Cato.

    BD funded the project. While this can raise some red flags, I don’t think it’s enough to disqualify the data. Other companies, like Baxter, sponsor half of the sessions on compounding safety at ASHP Midyear. I for one am happy they do it. Support from companies like BD and Baxter go a long way in bringing important topics like compounding safety to the masses. So, focus on the use of gravimetrics, not on the company that sponsored the paper.

    *Terkola R, Czejka M, Bérubé J. Evaluation of real-time data obtained from gravimetric preparation of antineoplastic agents shows medication errors with possible critical therapeutic impact: Results of a large-scale, multicentre, multinational, retrospective study. J Clin Pharm Ther. 2017;00:1–8. https://doi/org/10.1111/jcpt.12529

  • Laying the foundation for your technology implementation team

    I’ve been thinking a lot lately about the right way to go about putting new technology into a pharmacy. Making the decision to add technology doesn’t mean running out and purchasing a million-dollar piece of equipment and shoving it in a corner. It’s much more complicated than that. You must first lay the foundation for the work to be done.

    Here are some things that I think should be considered before putting new technology in the pharmacy:

    Give everyone fair warning of what you plan to do. No one likes to be surprised and people fear change. The best policy is to give people plenty of warning before making a change, which will allow them to get used to the idea. This will go a long way in gaining support for the project. Being aware of what’s coming is always preferable to being surprised by what has already been done.

    Gauge user beliefs and feeling. It’s best to take the temperature of pharmacy personnel prior to getting started. Is it going to be an uphill battle? Are the pharmacists and technicians open to the idea of implementing new technology? Is the pharmacy morale where it should be? Does your department fear change?

    The success of the implementation depends heavily on how well the department is warned and prepared for the change. People often see technology as a threat to control over their work environment, resulting in pushback. Helping staff understand what it is you hope to accomplish, how it will help them, and offering opportunities for staff to become vested in the project can go a long way in ensuring a successful implementation.

    Get support/buy-in for the project. Support for any project is a must. Recruit from the top of the organization to the bottom. Failure to do so may result in a failure to launch.  Whenever possible it is best to have support from the highest level of the organization, executive sponsor or someone from the board if you have one.  Influence matters. And don’t forget to involve all departments that will be impacted by the change, including nurses and physicians when appropriate.

    Create a buzz. Create some excitement. Don’t act like the project is required, but rather a choice that’s going to make things better.  This is the power of advertising. We fall for it all the time, from cars to smartphones.

    User involvement and participation. When individuals believe that the implementation of technology is relevant, they are much more likely to have a positive attitude toward the project. The best way to get individuals to believe in the technology is to get them involved and allow them to participate in all phases of the project. “Increasing user participation … enhances post-development user involvement and attitude”.(1)

    Involve as many people as possible as often as possible. When people are involved, it gives them a sense of ownership, making them vested in the project’s success. It also helps deal with negative vibes that may come from others.

    Volunteers only. It is important that all participants be volunteers as mandated participation has been shown to be ineffective and potentially detrimental to the success of this type of project. (2)

    Champions. Champions are the people that go above and beyond the general participant. Champions believe in the technology and the benefits it will provide. They can often have a contagious zeal about the project, and are sometimes referred to as “evangelists”, or in extreme cases “zealots”. Whatever you call them, you need them. When it comes to implementing new technology in the pharmacy, champions can be your best source of support and are often useful in putting a spotlight on the project in a positive way while swaying negative feelings about the project. 

    Finding Champions shouldn’t be too difficult. There are usually early adopters in every group. They will often present themselves while taking the initiative to learn more about the project without being asked.

    Develop rules for participation. This is really quite simple. It is important that the rules for participation be laid out well in advance, and that each member of the team signs off on them. There should be no surprises for what’s expected from participants once the project is underway. The following rules are examples:

    • Be willing and able to engage in the project
    • Be willing to be positive about the project
    • Be willing to work with others to advance the project
    • Be willing to commit to attending meetings
    • Be willing to commit to handling extra work, even if it means staying late or doing some reading at home in the evenings or on the weekends. I understand that no one wants to put in a bunch of unpaid overtime on these projects. However, on occasion, a little extra work needs may need to be done to keep things moving forward. One should enter into participation with the understanding that this could happen.
    • Be willing be engage in every aspect of the project, not only the items that are assigned. It is vitally important that each participant has at least a basic understanding of the overall scope of the project and what each member of the team is assigned to do. Things happen. People get sick, quit their jobs, move to another state, and so on. Such unforeseen events should not completely derail the project timeline or goals. 

    Sway the naysayers. Every project has its opposition. As the saying goes, you can’t please everyone all the time. Unfortunately, naysayers tend to be the most vocal personalities in any group. They’re not afraid to say what’s on their mind; whether positive or negative. The downside is that outwardly negative comments about a project have a way of spreading like wildfire. They’re caustic and often seep into the minds of even the staunchest supporter without warning. And once planted, negative thoughts grow like a cancer.

    Naysayers and their negative comments have their place. They often point out things that others fail to see, helping avoid pitfalls along the way. The trick is to use the information to your advantage and allow naysayers to offer their thoughts in an environment that won’t bring down the rest of the pharmacy. Give them space to vent, and then do your best to use the information to flip them. If you can show the naysayers in the group that you’re willing to listen to them and take their concerns seriously, you may be able to get them on your side. That’s a huge victory for any project. On the other hand, never force change on a naysayer. Forcing change or mandating them to join your side rarely works. It’s like dealing with a donkey, the harder you pull, the harder they resist.

    Build a team with high potential for success. According to Harvard Business Review’s (HBR’s) 10 must Reads On Emotional Intelligence (3), the source of great success lies with teams that can achieve high levels of participation, cooperation, and collaboration among members.

    Team members must be chosen carefully and meet three basic conditions:

    1. Mutual trust of one another
    2. Have a sense of group identity – a feeling that they belong and the project is worthwhile
    3. Have a sense of group efficiency – belief that the team can perform well and that the group is better than the individual members.

    Collectively, HBR refers to this as the groups “emotional intelligence” (EI). And while the knowledge and experience among group members is important, EI may be more important still. Keep this in mind when you begin building the project team.

    Chose a project leader. Being “the leader” is a burden that many well-qualified individuals shy away from. With that said, someone has to be in charge. Someone has to be given authority over the group. Someone has to be willing to make the tough decisions and hold people accountable.

    Not everyone is cut out to be a leader. I am of the opinion that leaders are born, not made. You either have it or you don’t. I know because I’ve tried many times to lead and failed. It wasn’t for lack of knowledge or desire, but rather a lack of natural leadership and charisma. On the flipside, I’ve been around many people that just have “it”; “it” being a knack for getting people to follow them and do what they say, i.e. they’re natural born leaders.

    What distinguishes good leaders from great leaders is “a group of five skills that enable the best leaders to maximize their own and their followers’ performance.” (3)

    The five skills are:

    • Empathy
    • Motivation
    • Self-regulation – controlling negative impulses
    • Self-awareness – knowing strengths and weaknesses
    • Social skill – being able to build a rapport with others to get desired results

    Find a project manager. As ridiculous as this may sound, the project manager is an often overlooked position when discussing project teams. Let me go on record now as saying that a good project manager is absolutely vital to the success of any project; arguably the most vital consideration to the success of a project.

    It is the job of the project manager to manage all aspects of the project, including the scope, the timeline, the cost, the quality, and the people. They apply their knowledge, skills, tools, and techniques to help projects be successful.

    “The role of the project manager is that of an enabler. Her job is to help the team get the work completed, to “run interference” for them, to get scarce resources that they need, and to buffer them from outside forces that would disrupt the work.”(4)

    Things to consider when selecting a project manager:

    1. The person must have leadership qualities, have good self-management and time management skills, and be a taskmaster.
    2. The project manager cannot serve two masters. Individuals that serve as a project manager must not be required to do any of the actual work in the project. According to Lewis (4), “as team sizes increase, it becomes impossible to work and manage both[the work and the team], because you are constantly being pulled away from the work by the needs of your team members”. Having project managers attempt to manage the project in addition to working on the project is a recipe for disaster.
    3. The person must have a proven track record. We all know people that can’t manage the paper piles in their office much less a multi-faceted project requiring meticulous attention to detail.

    I encourage everyone involved in a large project to read a book or two on project management. Being a project manager is not as easy as it sounds and should be given the respect it deserves.

    That’s it. Piece of cake. Go forth and build your implementation team.

    —

    • Vaughan PJ. Internal Report of Information Technology Services. University of Colorado at Boulder. 2000.
    • Hunton, J.E. and Beeler, J.D., Effects of User Participation in Systems Development: A Longitudinal Field Experiment. MIS Quarterly, 21(4), 1997, pp. 359-388.
    • Hbrʼs 10 Must Reads On Emotional Intelligence. 1st ed. Boston (Massachusetts): Harvard Business Review Press, 2015. Print.
    • Lewis, James P. Fundamentals Of Project Management. New York: American Management Association, 2007. Print