Medication Errors

The tail wagging the dog

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WSJ: “The Food and Drug Administration said Tuesday that it will require some painkiller manufacturers to produce new educational tools in an effort to quell prescription-drug abuse. The requirements will affect makers of long-acting and extended-release opioids, which include oxycodone, morphine and methadone. Letters have been sent to manufacturers of the drugs describing the medication … Read more

Healthcare is beyond repair, and I can prove it

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Before we begin let me get a few things out of the way. First, I am a healthcare professional. Yes, a pharmacist is a healthcare professional. Second, I’ve spent a large portion of my adult life working in the healthcare industry, both inpatient and out. This includes more than a decade working in a hospital as either a “staff” pharmacist or a “clinical” pharmacist. Third, the average person has no idea what goes on in a hospital or their physician’s office. A majority of people that are misdiagnosed, receive unnecessary labs, get the wrong drug, etc. will never know because they have no reason to think they’re getting anything but the best of care. And finally, I’ve been called a pessimist. I don’t see it that way, but I’m simply giving you all the data I have.

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Realistic view of medication reconciliation?

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Hospitals & Health Networks: “Despite progress, medication reconciliation remains a bitter pill. Un-intended changes in medications occur in one-third of all patients transferred between hospital departments, and in 14 percent of patients at hospital discharge, according to the Agency for Healthcare Research and Quality. Most medication inconsistencies could be avoided if reconciliation were performed at … Read more

BCMA Technology: Characterization of Med Triggers and Workarounds (Article)

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There’s an interesting article in the February 2011 issue of The Annals of Pharmacotherapy dealing with BCMA and what the author describes as “clinical workarounds”.1 Abstract BACKGROUND: Bar code medication administration (BCMA) technology is gaining acceptance for its ability to prevent medication administration errors. However, studies suggest that improper use of BCMA technology can yield … Read more

Do smaller hospitals get the shaft when it comes to automation and technology?

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I’ve worked in several acute care hospitals during my career, from the small one horse operation that did little more than care for minor inconveniences, to larger, multi-pharmacy facilities that handled everything from pneumonia to severe trauma. As I’ve mentioned elsewhere on this blog each one of those pharmacies offered a slightly different way of doing things. Granted, some were variations on a similar approach, but they were all different.

However, one trend I’ve discovered across the range of facilities is that the smaller the hospital, the less automation and technology the pharmacy has. Why? It’s quite simple. Automation and technology is expensive. It’s also time consuming to plan for, implement and maintain. Of course another argument is that smaller hospitals - and therefore smaller pharmacies – need fewer technological advances. That doesn’t make much sense to me. I agree that a small 50 bed hospital pharmacy may not need a giant robot to fill their med carts, but they can certainly benefit from clinical decision support, pharmacy surveillance software, bar code medication administration (BCMA), computerized provider order entry (CPOE), automated dispensing cabinets (ADCs), smartpumps, mobile devices, so on and so forth. The problem is that much of this technology is expensive and takes a sizable chunk out of smaller budgets.

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S.A.L.A.D.

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Sound-Alike, Look-Alike Drugs (SALAD) have recently floated to the top of my attention with the release of the Institute for Safe Medication Practices (ISMP) recommended list of Tall Man Letters for look-alike drugs. I mentioned the new list on Twitter which resulted in a short, but interesting conversation with some colleagues.

SALADs have been problematic for quite some time and many solutions have been proposed, including Tall Man Lettering, physical separation of look-alike drugs, printing of both brand and generic names on packaging and storage bins, use of colorful warning labels, and so on and so forth. The problem with all these solutions is human involvement. Working in acute care pharmacy has taught me over and over again that all the above systems may decrease error, but certainly don’t eliminate them.

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CPOE failure modes and effects analysis brings up some good questions

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A Failure modes and effects analysis (FMEA) is basically a methodology for predicting potential pitfalls in a project and preemptively finding solutions. This is in contrast to a root cause analysis (RCA) in which case you figure out what went wrong after the fact. Kind of like asking “what could make a plane crash and how to prevent it?” (=FMEA) versus “what made the plane crash and how do we prevent it from happening again?” (=RCA).

My current position is the first in which I’ve been involved in an FMEA, and I’ve personally found them to be powerful tools. We did an FMEA prior to implementation of our BCMA system and came up with what I thought was a pretty good list of things to look out for. Of course what the administration chooses to do with that information is a different story, but at least it’s available if needed.

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Drug error occurs, but not for the reasons you’d expect

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I was reading through the most recent issue of the ISMP Medication Safety Alert! and came across an incident where a CLINIMIX E solution was infused on a patient prior to being mixed, resulting in the patient receiving a concentrated dose of amino acids and electrolytes. Fortunately no harm was done. CLINIMIX E is a … Read more