IV workflow management systems and workarounds

A large portion of the most recent issue of the ISMP Medication Safety Alert is dedicated to IV workflow management systems (IVWFM) and errors caused by workarounds. There are a few head-scratchers in the list to be sure. There are even some that had me speculating their authenticity, i.e. too wacky to believe.

Data submitted to the ISMP National Medication Errors Reporting Program (ISMP MERP) have repeatedly shown that manual verification of intravenous (IV) admixture ingredients by pharmacy personnel who prepare solutions and pharmacists who inspect the final products is not particularly effective in detecting and correcting errors.” You can take this to the bank! Rule #1: people are people. They make mistakes and do crazy things sometimes. Rule #2: no amount of technology will eliminate rule #1.

However, as with any new technology that introduces an element of change, we want you to know about the workarounds and errors we have learned about with WFMS and why they may be happening so you can be as prepared as possible to address the when you assess or implement this technology. Some of these workarounds or errors are common to many other forms of healthcare technology.”

This is no doubt true as I’ve witnessed workarounds with pharmacy technology on many occasions.The sad truth of the matter is that no amount of technology will prevent people from finding workarounds. Just like no amount of manual processes and double checking will prevent workarounds. Unfortunately, these workarounds can lead to mistakes, which is what we are ultimately trying to prevent.

Typically, it is a combination of well-defined processes with appropriate technology that creates the safest environment. It’s also the best way to prevent workarounds. That and opening a can of whoop ass on people that don’t follow the rules; figuratively speaking, of course.

Here are some of the potential workarounds and errors identified by ISMP, many of which are similar to those seen with bar-code medication administration (BCMA):

Inability to scan the barcode — This is a common problem with any bar-code scanning process, i.e. BCMA, etc. Barcodes are far from perfect and will never be 100% scannable.

Reluctance to scan the barcode — Human nature. Go figure.

Scanning just one vial — i.e. scanning a “representative vial” when using more than one vial during CSP prep. Happens all the time.

Using a decoy for scanning or image capture — the old barcode-in-the-pocket scam.

Using the syringe pull-back method — hard to imagine that this is still going on in pharmacies across the country. It should be banned. Any facility caught using the syringe pull-back method should be fined heavily and mocked openly for their laziness.

Blurry or missing digital images — I’ve experienced this personally. Here are some images from one popular IVWFM system that were given to me. Can you tell, without any doubt, what the volumes are in these syringes? [If anyone has any sample images, I would love to see them]

Lapses in technique. “Use of WFMS touch screens can lead to touch contamination, especially when handling hazardous drugs. This and other lapses in hazardous drug handling and aseptic technique are not easily captured by the WFMS and may go unnoticed.” — No doubt a problem. Regardless of what technology you add to your process, proper technique in the hood is a must.

Interference with the scale. “ISMP has received a report about a WFMS with gravimetric technology for which the scale would not work in a laminar airflow workbench/biological safety cabinet due to vibration. Every time the pharmacy technician needed to weigh a product, he or she had to turn off the hood [what the heck!].” — not all gravimetric solutions are equal. There are at least two IVWFM systems on the market that do a great job with their gravimetrics. There is at least one that doesn’t. Any facility considering this technology should make sure to do their homework.

A “no-mistakes sponge system” — bar-coded sponges in the OR

While not directly related to pharmacy, the SurgiCount Safety-Sponge System is kinda’ cool. The system uses low-tech barcode technology to prevent surgical sponges from being left behind in patients. Simple yet effective.

The system uses sterile bar-coded sponges and a computer tablet loaded with proprietary software to ensure that all sponges are tracked. After approximately 11 million surgical procedures over the last five years, which involved the use of more than 200 million sponges, the system boasts zero sponges left behind.” source: MLive

The lowly barcode gets a bum wrap sometimes. It’s far from perfect, but overall I believe the use of barcodes has improved safety throughout the healthcare environment. I remember just a few short years ago when barcode scanning was uncommon. Now, not so much. “Overall, 92.6% of hospitals have barcode-assisted medication administration (BCMA) systems to verify patient identity and electronically check doses administered by nurses (Table 2). Over the past 13 years, the percentage of hospitals having BCMA has increased from 1.5% in 2002.“(1) I get calls in the pharmacy from nurses refusing to administer medication because they’re unable to scan the medication barcode. We’ve come a long way.

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(1) Pedersen C, Schneider P, Scheckelhoff D. ASHP national survey of pharmacy practice in hospital settings: Prescribing and transcribing—2016. American Journal of Health-System Pharmacy. 2017;74(17):1336-1352. doi:10.2146/ajhp170228.

Pearson Medical Technologies introduces m:Print Version 3.9.1

This came through one of my Google Alerts this morning.

Life Pulse Health Magazine: “Pearson Medical Technologies’ [PMT] … m:Print Version 3.9.1 has been updated to use Microsoft SQL Server 2012/2014 for more efficiency and advanced performance. Each packaging run can now automatically generate a unique lot number. Most importantly, Pearson Medical has added a bar code constructing module which allows users to add more than one drug information into a bar code… in addition to the release of a new version of m:Print , we have selected Medi-Span to provide the drug database for use within m:Print.”

m:Print is a great stand-alone option for pharmacies looking to print bar code labels for vials, ampules, syringes, IV bags, etc. The system is well liked by many. In fact, PMT has OEM’d m:Print for other companies as their bar code printing solution. So if you have an inventory management system from another company and m:Print looks familiar, that’s probably because it’s the same software, minus some minor UI tweaks.

I personally like m:Print, mostly due to its flexibility. It offers the ability to use virtually any printer or label type. You can customize labels just about any way you see fit, including the use of 2D and/or linear bar codes.

I had the opportunity to get a sneak peak of m:Print version 3.9.1 prior to its release. Overall, there are some nice improvements. Chances are, if you liked the system before, you’re probably going to like it even better now.

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Disclaimer: as a consultant, I’ve done work for PMT and with companies that have partnered with PMT.

Does charge-on-chart hurt or help medication chain of custody?

Historically, hospital pharmacies have used a charge-on-dispense (COD) model for medications. The model charges the patient for a medication when it is dispensed from the pharmacy and credits the medication if it’s returned to the pharmacy unused. Simple, but labor-intensive. The model itself has been around for a long time.

The introduction of electronic health records (EHRs) and electronic medication administration records (eMARs) has pushed the COD model aside in favor of the charge-on-chart (COC) model; sometimes referred to as “charge on administration” (COA). In the COC model, the patient isn’t charged for a medication when it is dispensed from the pharmacy because the charge is captured when the medication is scanned by the nurse and administered to the patient. When the nurse scans the medication, the information is captured by the eMAR and charted, hence the name. There are several benefits to this model, including no need for the pharmacy to credit medications that go unused. Unused medications are simply returned to the pharmacy and folded back into the inventory.

Put simply, the COC model eliminates the need for pharmacies to charge and credit medications as they are dispensed and returned to the pharmacy. But here’s a little untoward side effect of the COC model, it eliminates much of the pharmacy audit trail for medication movement into and out of the pharmacy.

The old COD model wasn’t perfect, and there were plenty of discrepancies, but I wonder if the COC model has created even less transparency regarding inventory reconciliation and the movement of medications throughout the hospital.

Inventory management systems like AutoPharm from Talyst and Pyxis Pharmogistics from Carefusion should, in theory, give pharmacies real-time inventory numbers. But the promise of these systems has fallen short. Both utilize barcode scanning to track inventory, which unfortunately requires humans to be diligent when scanning items in and out of inventory. Human laziness usually prevails, and numbers are frequently inaccurate.

Medication tracking systems are available from a couple of companies, but also utilize barcode scanning, thus fall prey to the same weakness mentioned above. These systems also fall short when following medications throughout the medication distribution process as they typically stop as soon as the medication is delivered to the nursing unit, i.e. they don’t track the return of the medication.

Track and trace regulation, which will require serialized barcodes and tracking from manufacturer to patient, could potentially help with this issue. However, that process has the same weaknesses as those mentioned above, namely human intervention.

RFID technology would surely be better than barcode scanning, except that RFID tags are too costly for use on all medications and drug manufacturers are nowhere near ready to do anything like this.

Currently, the only medications that receive enough scrutiny in a pharmacy to determine location and quantity at any given moment are controlled substances, i.e. morphine, fentanyl, oxycodone, and so on. And this falls short on some level once the medication leaves direct oversight of the pharmacy.*

It’s interesting to think that as much time as we spend managing inventory in a hospital pharmacy, we still have a long way to go.

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*This includes leaving the pharmacy itself as well as storage devices like automated dispensing cabinets (ADC). When a medication leaves the ADC we assume it has been administered to the patient once it has been charted. We cannot confirm this, however. For all we know, the healthcare provider that removed the medication and documented the administration, simply put it in their pocket and walked out with it. You never know for certain.

ISMP responds to deadly drug error in Oregon

Last week I wrote about the tragic death of a patient caused by a drug error (CSP error results in death of a patient). One day later on December 18, 2014, ISMP also addressed the error in the Acute Care edition of their biweekly ISMP Medication Safety Alert, i.e. one of their newsletter. I had hoped that ISMP was going to provide much greater detail and insight into the error, but that’s not the case. At least not at this point, anyway.

I had hoped to find out what occurred in the pharmacy to allow such a mistake to happen. Perhaps more details will come to light as time goes on. All we can do is wait.

With that said here are some things from ISMP worth noting:

To prevent inadvertent use, identify neuromuscular blockers available within your organization and where and how they are stored. Regularly review these storage areas, both inside and outside of the pharmacy, including agents that require refrigeration, to consider the potential for mix-ups.

Limiting access to these products is a strong deterrent to inadvertent use. Consider limiting the number of neuromuscular blockers on formulary, and segregate or even eliminate storage from active pharmacy stock when possible.

Restrict storage of paralyzing agents outside the pharmacy and operating room by sequestering them in refrigerated and nonrefrigerated locations.

ISMP recommends highly visible storage container for neuromuscular blockers (one example here: www.ismp.org/sc?id=458).**

ISMP recommends affixing warning labels on vials and admixtures that clearly communicate the dangers of neuromuscular blockers.**

ISMP recommends the use of IV workflow technologies. “Now is the time for hospital leadership to support the acquisition of IV workflow technologies that utilize barcode scanning of products during pharmacy IV admixture preparation.” While the article lists only three systems, there are several on the market [see  In the Clean Room TOC for a current list of many of the available systems].

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**I know that many think this is a good idea, but I’m not so sure that I’m one of them. On the surface, using highly visible storage containers and labels might seems like a good idea, but over time people become used to the idea and become blind to the differences. In addition, over the years the number of items that require alternate storage and labeling has grown, making differentiation “the norm”. It’s like the student that highlights everything in the textbook with five different colors. Eventually the entire book is highlighted, making the process meaningless to the reader.

Cool Pharmacy Technology – Eyecon Visual Counting System

It’s hard to imagine that pharmacies still manually count medications and pour them into bottle for distribution to patients, but it goes on all the time. Even large pharmacies that have robotic dispensing systems still have to manually dispense a fair number of medications for one reason or another.

Eyecon by RxMedic is an automated counting system for oral medications that uses barcode scanning technology and “machine vision” to ensure accurate medication dispensing.

Some things that I thought were interesting about Eyecon:

  • It uses barcode scanning technology to ensure that the correct medication is being used, i.e. Eyecon scans the medication barcode against the prescription label. When used properly this a good way to prevent putting the wrong drug in the patient’s bottle.
  • Use of “machine vision” to perform counting. I’m not entirely sure what “machine vision” technology is, but I hear the term often enough; especially when looking at compounding robots. According to the company, Eyecon can “detect pill fragments or foreign matter in the counting platter and alert the operator”. That’s a nice feature.
  • There are separate trays for “sulfa” and “penicillin”. You frequently see tray segregation like this in outpatient pharmacies due to fear of cross contamination and patient allergies. This little feature tells me that the person that designed Eyecon has practical experience in a pharmacy.

Couple of Eyecon videos below. The first shows a general overview of Eyecon from 2010. The second shows Eyecon being used to fill a prescription using barcode scanning technology. There are several videos posted on YouTube. Just search for “Eyecon”.
Continue reading Cool Pharmacy Technology – Eyecon Visual Counting System

Bar-Coded Medication Preparation for Chemotherapy [article]

The September 2014 issue of Pharmacy Purchasing & Products contains an article on the use of bar code scanning during the preparation of compounded sterile products (CSPs).  The article touches on some of the topics that Mark and I cover in our report, In the Clean Room; errors in the IV room, bar code scanning during medication preparation, image capture, remote verification, and so on.

Continue reading Bar-Coded Medication Preparation for Chemotherapy [article]

Saturday morning coffee [July 26 2014]

“Everything happens for a reason, and sometimes that reason is you’re stupid and make bad choices” – unknown

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….

The coffee mug below is relatively new. I received it as a gift from my brother Robert and his wife, Kim. Very cool. I’ve had a running joke about monkeys for years. Once upon a time, not too many years ago, an administrator in the pharmacy where I worked told me that a monkey could do my job. Made me pretty angry. Sad part was he was right.

MUG_Monkey
Continue reading Saturday morning coffee [July 26 2014]

RFID vs barcode technologies

MedKeeper: “Based on similar use cases, the comparison between bar code and RFID technologies is inevitable. Several papers have reviewed the use of these technologies in hopes of defining best practice. Young concluded that a coordinated use of these technologies might provide the best compromise between implementation costs and potential benefits.   RFID technology, with its high cost, may be most appropriate for patient identification, while the lower cost of bar code systems may be more appropriate for material inventory.[3]

Sun et al.[4] arrived at a similar conclusion. In this case, the authors evaluated medication error reduction. Due to the high cost of RFID tags and readers the authors proposed a system utilizing less costly bar codes for unit-dose medications while using an RFID-embedded wristband worn by patients for identification.”
Continue reading RFID vs barcode technologies