Small labeling changes to phenytoin unit dose cup causes confusion

August 12, 2010 issue of the ISMO Medication Safety Alert the issue of : “We have received a number of reports about the labeling of Xactdose unit dose liquid containers from VistaPharm, Inc., of Birmingham, AL. The company recently changed the way the drug concentrations are expressed on their labels. An example is phenytoin oral suspension which went from emphasizing 100 mg/4 mL to listing 125 mg/5 mL. The company rightly notes that the 125 mg/5 mL container delivers 100 mg or 4 mL (due to the heavy liquid consistency of phenytoin suspension), but the message doesn’t necessarily translate to nurses who are confused by the new label and need to give an exact dose. The good news is, we learned last week that VistaPharm is returning to the old style label. That will no doubt lead to less confusion, but nurses should also know not to rinse the residual suspension from the cup. Doing so would approximate as much as a 25% overdose. The company said they expect to release products with revised labeling by the end of the month.”
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Is the 30-minute rule for medication administration good or bad?

The June 17, 2010 issue of ISMP Medication Safety Alert I received has an interesting article on the unintended negative consequences of the Centers for Medicare & Medicaid Services (CMS) regulation requiring medications to be administered within 30 minutes of their scheduled dosing time. I’m sure that the CMS 30-minute rule was created with good intentions in mind, but in reality it creates a lot of anxiety and bad habits. According to the ISMP article, the CMS 30-minute rule “may be causing unintended consequences that adversely affect medication safety. While following the 30-minute rule may be important to hospitals, many nurses find it difficult to administer medications to all their assigned patients within the 30-minute timeframe. This sometimes causes nurses to drift into … unsafe work habits.” Those unsafe work habits include removing meds from automated dispensing cabinets (ADC) for multiple patients at once, removing meds ahead of time, falsifying documentation to meet the 30-minute rule and preparing doses ahead of time; all dangerous practices.
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An almost disastrous bar-coding mishap

At some point in the past few days it was decided that our technicians should re-label all injectable controlled substances with one of our “after market” flag labels. I’m not sure when or how the decision was made, but it was. When questioned about it, the rationale behind the decision was that the nurses were wasting unused medication at the ADCs and not taking the vial to the bedside. And apparently the solution was to use our flag labels because they offer a peel away section that can be taken to the bedside with the drug in a syringe for scanning and administration purposes.
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A look at one pharmacists unwanted potential

A recent post by John Poikonen got me thinking about medication errors. They’re part of every pharmacists day, but we rarely give them much thought.

I’ve been a pharmacist for more than 10 years now and I’ve make my fair share of mistakes. I would like to think that none of those errors caused harm, but that would be naïve to say the least. And forget about the errors that were never detected because one can only speculate about those.
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We need a better system for medication reconciliation

Medication reconciliation is defined by JCAHO as “the process of comparing a patient’s medication orders to all of the medications that the patient has been taking. This reconciliation is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions.” The process should be fairly straight forward, but it is actually very difficult and time consuming.
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Sad, but all too common experiences with healthcare

I read Warner Crocker’s musings at GottaBeMobile as well as his Tweets via the @LPH/tablet-pc-enthusiasts list on Twitter. Warner also has a second blog called Life On the Wicked Stage: Act 2, which I do not read with any regularity. I was, however, driven toward his personal blog secondary to a Twitter post. The post, titled Rush and My Mom: Two Different Care Experiences, talks a little about his experiences with his mothers medical care. She is apparently very ill with lung cancer. I sympathize with Warner as my mother-in-law, Mary Lou, succumbed to lung cancer in December of 2008. I also understand much of what he is talking about as my wife and I experienced similar problems during Mary Lou’s chemotherapy, pain management and surgeries.
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Who should collect allergy information and how should it be done?

pulling out hairA pharmacists review of a patient medication regimen is never complete without a thorough evaluation of the patients allergy history. Unfortunately our hospital information system suffers from the inability to prevent people from being human and making mistakes. Our clinical information system permits ‘free texting’ of allergy information, resulting in misspelled drug names and therefore allergies that aren’t electronically checked against medication orders. You know the old saying: garbage in, garbage out.
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For those that need a reason to support CPOE and EMR implementation

Pharmacists see hand written orders like the one below almost daily. The order has to be interpreted by a pharmacist, usually with a little hand waving and guessing (kind of like being a pharmacy Jedi), and entered on the patient’s medication profile before the nurse can access the medication from the automated dispensing cabinet and get it to the patient. Even though I’m used to looking at orders like this, there is simply no excuse for what you see below.

There are two medications contained in the hand written orders below. I double-dog dare you to find them. It’s kind of like a “Where’s Waldo” puzzle. Leave your guesses in the comment section of this post. Good luck.

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ugly_order

A couple of articles on medication errors worth reading

The entire June issue of the British Journal of Clinical Pharmacology (BJCP)  is dedicated to medication errors. It’s worth your time to browse all the articles, but the two below were of particular interest to me.

Agrawal A. Medication errors: prevention using information technology systems. British Journal of Clinical Pharmacology. 2009 ;67(6):681-686.
The article covers all the usual suspects when it comes to reducing medication errors via technology. Technologies discussed include CPOE, barcoding, BCMA, medication reconciliation, personal health records, automated dispensing cabinets and decision support systems. No great amount of detail was presented, but the article is well referenced. The entire abstract can be found here.

Cheung K, Marcel L. Bouvy, Peter A. G. M. De Smet. Medication errors: the importance of safe dispensing. British Journal of Clinical Pharmacology. 2009 ;67(6):676-680.
The article discusses several strategies for reducing dispensing errors, including barcoding and automated carousels. For each strategy presented, the authors provide some level of support found in the literature. The article is worth adding to your collection. The entire abstract can be found here.

One final item worth mentioning is a brief editorial written by J K Aronson, the President of the British Pharmacological Society. In it he states “Computerized systems can contribute to prevention as well as detection, but they are expensive and can generate their own forms of error. Simpler and cheaper methods are available and should be widely implemented. For example, error reporting is important in both detection and prevention, and pharmacovigilance has a role to play. However, chief among the preventive methods is education.” – I find this statement both insightful and accurate.