Saturday morning coffee [December 15 2012]

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….

Pike Place Market Starbucks Coffee MugThe coffee mug to the right comes from Pike Place Market in Seattle, WA, home of the first Starbucks Store. I got the mug on my first trip to Seattle, which just so happened to be during a trip to give a presentation for the company I currently work for. I wasn’t an employee at the time, but they invited me up to talk about the automation and technology that we were using in our pharmacy at Kaweah Delta Medical Center where I was employed as an “IT Pharmacist”. One of the things I really wanted to do during my visit there was visit Pike Place Market and see the first Starbucks. My brother, Robert used to work in Seattle and he gave me a list of things to do and see. I only managed to get  to a few of things on the list, but this was one of them. The first Starbucks is different from any other Starbucks I’ve ever been to. It doesn’t have that corporate-lets-make-money feel to it.

Here’s an interesting twist at the box office, Skyfall continues to do well as it rose back to the#1 spot last weekend. Good movie, highly recommended. Rise of the Guardians came in at #2.  This of course will be short lived as The Hobbit: An Unexpected Journey will kill at the box office this weekend. There is no doubt that I will see The Hobbit, but I must say that the reviews have not been flattering. I read the book as a child and again as an adult.
Continue reading Saturday morning coffee [December 15 2012]

More on the meningitis outbreak caused by contaminated steroid injection

Things just keep getting worse: death toll rose to 14 and people affected was up to 172 in 11 states as of this afternoon. It’s difficult to find accurate information on the exact cause of the meningitis, but it appears that most of the cases are related to either Aspergillus or Exserohilum.

Fungal infections are notoriously difficult to treat, especially when they’re in the central nervous system (CNS). The CNS is designed like a fortress to keep things out, like fungus and bacteria, thus keeping you safe and healthy. Unfortunately it doesn’t discriminate and does a great job of keeping medications out as well. That’s why it’s hard to treat infections in the CNS.

I’ve been involved with several meningitis cases over the years, but rarely those involving a fungus. The outcome generally depends on several variables including how quickly the infection is discovered, how soon treatment is started, how aggressive the treatment is – you can never be too aggressive when treating meningitis – and the general health of the person you’re treating. A little divine intervention is always desirable as well. However, as I mentioned above, meningitis is difficult to treat and the outcomes associated with fungal meningitis aren’t great.

The CDC has released treatment recommendations. You can find them at the ASHP Pharmacy News site here.

“The Centers for Disease Control and Prevention (CDC) recommends i.v. voriconazole and liposomal amphotericin B as initial therapy for patients who meet the current case definition for fungal meningitis.

According to CDC, the antifungal therapy for patients with meningitis should be administered in addition to routine empirical treatment for potential bacterial pathogens.

CDC Medical Epidemiologist Tom Chiller said during an October 10 conference call that broad-spectrum antifungal therapy is advisable because it is “unclear as to how many potential fungal pathogens could be involved” in the outbreak.

For patients who meet CDC’s current case definition for fungal meningitis, the recommended dosage of voriconazole is 6 mg/kg administered every 12 hours. Chiller said the dosage should be maintained “for as long as the patients tolerate it.”

Liposomal amphotericin B should be administered intravenously at a dosage of 7.5 mg/kg/day, according to CDC. The agency stated that liposomal amphotericin B is preferred over other lipid formulations of the drug.

The optimal duration of therapy is unknown but is presumed to be lengthy.”

Emphasis above is mine.

Saturday morning coffee [July 21 2012]

So much happens each and every week that it’s hard to keep up sometimes. Here are some of the taps that are open in my browser this morning along with some random thoughts….

The coffee mug to the right is in honor of the new Batman movie, The Dark Knight Rises. I am a Batman fan from way back. Don’t believe me, ask my brother. I was reading the comic books, a.k.a. “graphic novels” long before Michael Keaton invented the movie role back in the late 80’s. The mug itself comes from Six Flags Magic Mountain down in Valencia, CA. Six Flags is a DC Comic themed park, so of course they have a lot of Batman paraphernalia. The park is only about three hours from my home so my family and I have season passes and head down there 2-3 times a year. I don’t do roller coasters anymore, but my kids enjoy them. Me? I eat my way around the park; freshly make sugar-cinnamon donuts, ice cream, popcorn, churros, and of course funnel cake. Don’t forget about the funnel cake. I get mine with whipped cream, strawberries and chocolate sauce. Been thinking about piling ice cream on top, but haven’t gone that far yet.
Continue reading Saturday morning coffee [July 21 2012]

Sadly #ASHP misses the mark

I’ve been an ASHP member off and on for much of my career. I’m not much for membership in organizations, but I thought ASHP would be worthy. Heck, they’re the biggest professional pharmacy organization in the country (world?), why wouldn’t I be a member.

I try to give them the benefit of the doubt, but sometimes I wonder who’s driving the bus. I believe ASHP’s goals should be to: 1) promote the profession, 2) improve the profession, 3) defend the profession from nefarious sorts, , and 4) offer guidance to help move the profession into the future. That’s it. Read into it what you will, but pharmacists and technicians pay to be members of ASHP. Why? Because they believe ASHP will make pharmacy better. Otherwise there’s no point.

I’ve dabbled in some of the small groups within AHSP, specifically the Section of Pharmacy Informatics and Technology (SOPIT). These small groups focus on specific issues within the profession. Their purpose is to come up with solutions and recommendations. And in the case of the SOPIT the goal is to help solve problems associated with pharmacy informatics, automation and technology within the practice of pharmacy. It’s actually a good group that has done some great things over the years.

One of these groups in particular had great promise as it brought together several companies in the industry to look at the problem associated with informational standards; particularly drug information updates to pharmacy formularies. One of the problems with information within formularies (drug dictionaries, drug masters, <insert other name here>) is that standards simply don’t exist. Everyone has their own way of doing it, which causes problems.

While serving as the IT pharmacist at my last facility I had to manually maintain several formularies: pharmacy information system, ADC’s, pharmacy inventory management system, barcode labeling system, online hospital formulary, etc. It was time consuming and fraught with error. And before you ask, yes I made mistakes in those systems that caused problems; problems that were a bear to fix.

The group mentioned above was brought together to look at this problem and propose a method for companies to collaborate with the sole purpose of bringing a single standard to the practice that could be utilized to populate hospital formularies in a “downhill” fashion, i.e. one formulary update delivered to a centralized location that could be pushed out to other formularies. One standard. One location to update. One  formulary to monitor. One formulary to maintain. Simple. Fewer errors. Less work. Better for the profession.

Unfortunately AHSP decided to kill the project. I’m greatly disappointed in ASHP for doing this.
Continue reading Sadly #ASHP misses the mark

Don’t ignore the evidence for the sake of argument

I regularly read a website called Medinnovation. It’s written by Dr. Richard Reece who tends to rant about healthcare in a refreshing way that you don’t often see online. He basically gives you his opinion with both barrels and it typically runs counter to what most people have to say. I like it.

This morning (broke my rule about Sunday morning reading, Doh!) I read his latest post, Medical Experts and the American People. This is one time when I think he got it wrong. In the article Dr. Reece basically chastises evidence based medicine (EBM). “I say “presumably” because many patients or doctors do not necessarily buy the experts’ advice [i.e. evidence based recommendations] or follow instructions.” Uh-oh.
Continue reading Don’t ignore the evidence for the sake of argument

The insidious nature of ignorance and my curiosity

There’s been a Tweet flowing through my Twitter stream for a few days now and I’ve avoided clicking on the link because I knew it would be something totally ridiculous, misleading and meaningless. Unfortunately it was a quiet Sunday morning, and while I sipped my coffee and waited for the rest of my household to come to life, I succumbed to human nature and clicked the link.

Grrr! I knew it. Something totally ridiculous, misleading and meaningless. What was I thinking? Why do I torture myself this way? One can only speculate.

Continue reading The insidious nature of ignorance and my curiosity

Digital edition of U.S. Pharmacist off to a bad start

I received the announcement below in my email just a short time ago. So being the good little pharmacist that I am, I headed on over to the U.S. Pharmacist website to check it out. Imagine my surprise when I clicked on the digital issue link and was greeted with a “Service Unavailable” message (bottom image). Bummer. Hopefully they’ll get it up and running shortly.

Update: Looks like they got it working within 5 minutes of me posting this. It’s a nice format. Check it out for yourself here.

Continue reading Digital edition of U.S. Pharmacist off to a bad start

Safety, privacy and UCSF Med Center’s failure to do the right thing

I am a UCSF School of Pharmacy alum. I consider UCSF Medical Center, along with many other people, to be one of the best medical centers in the country. And, UCSF Medical Center saved my mother’s life with a liver transplant earlier this year. However, I am frustrated with UCSF Medical Center this morning.

Continue reading Safety, privacy and UCSF Med Center’s failure to do the right thing

Fun with Lugol’s solution…not really

A recent ISMP Medication Safety Alert shared various errors that have occurred with Lugol’s solution over the ages. Lugol’s solution is a concentrated liquid form of potassium iodide and iodine known for its use in the treatment of hyperthyroidism. It’s also a dangerous drug because it’s typically dosed in drops, not mL’s.

Anyway, the ISMP alert shared several examples of oral overdoses with Lugol’s solution secondary to confusion between drops and mL’s. However, mixed in with all the “typical” errors, was the little gem below. Even though the error is more than a decade old, I can’t help but wonder “what the heck were they thinking!”. By the way, my initial read through had me thinking cursive “OS” (oculus sinister, i.e. LEFT eye). With that said, I wouldn’t have actually dispensed it because nothing else on the prescription fits.


One of the errors reported more than a decade ago involved an order to administer 10 drops of Lugol’s solution mixed with "OJ" (orange juice), but nurses misinterpreted "OJ" as OD (right eye). The patient received several doses of Lugol’s solution in his right eye. The error was identified when the patient complained to the physician about how painful the eye drops were.

Secundum artem. Yeah, not so much

imageMerriam-Webster defines secundum artem as "according to the accepted practice of a profession or trade". In pharmacy it typically goes hand in hand with the preparation of extemporaneous compounds, i.e. when you have to make something from scratch. Pharmacists have been doing this since the profession began. Unfortunately it’s a dying art not only because of lack of interest from younger pharmacists, but secondary to increased regulation and bureaucratic red tape as well. It’s a real shame. To put it in perspective it would be like surgeons no longer performing surgery by hand because of the invention of the da Vinci Robot.

Continue reading Secundum artem. Yeah, not so much