Counterfeit drugs are not only big business, they’re dangerous to consumers as well. Counterfeit medications have no quality assurance program, which means they can contain contaminants, sub-therapeutic levels of the active ingredient, the wrong active ingredient, or even no active ingredient at all. Thus they can cause more harm than good. While these medications can certainly cause problems here in the United States, it’s really the developing countries that are taking a beating.
(more…)
Tag: Medication Safety
-
Cool Technology for Pharmacy – Sproxil
-
CPOE failure modes and effects analysis brings up some good questions
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.
(more…) -
Drug error occurs, but not for the reasons you’d expect
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 dual chamber parenteral nutrition (PN) product consisting of two chambers separated by a seal. One chamber contains dextrose and calcium and the other chamber amino acids along with electrolytes. Simply bust the seal, mix the contents with some gentle agitation and hang it on the patient. Nothing could be easier. I loved these types of products when I used to work in the IV room. They don’t fit the bill for all patients, but when they do it sure makes life in the pharmacy simpler. Otherwise you have to make the PN from scratch which can be time consuming.
In the incident described in the ISMP article the CLINIMIX E bag was retrieved from the pharmacy after hours by nursing staff. This type of procedure is common in hospitals that don’t have a 24 hour pharmacy, i.e. small acute care hospitals. I think this type of system is dangerous, and certainly contributed to the mistake, but that’s not what stands out about this error.
The two things that really irritate me about this error are the physician’s directions and the nurses retrieving and starting a PN in the middle of the night. First and foremost, PN is never a life or death medication. Take a look at the ASPEN guidelines if you don’t believe me. PN is something that should only be used after serious consideration, and in a patient that has been NPO for several days. PN should never be used to adjust a patient’s electrolytes, temporarily augment a patients diet when they can eat solid food or to “stimulate appetiteâ€. In this case if the patient needed PN it could have easily waited until morning. And second, the physician in this case wrote for the CLINIMIX E to be given “’if the patient does not eat at least 50% of breakfast.†For those of you that think this order is ok, raise your hand. Now everyone look around and find the people that raised their hands. Make a mental note to never allow them to treat you for anything serious. Again, PN is serious business and not something that should be started based on an “if, then” statement. Either start it or don’t, but don’t write orders for PN that may be interpreted more than one way depending on who’s looking at it.
Errors occur too frequently in hospitals now, we certainly don’t need to make committing them any easier.
-
MedKeeper acquires DoseResponse
It looks like MedKeeper is making a play in the therapeutic monitoring market by acquiring DoseResponse, a web-based outpatient anticoagulation management system from Keystone Therapeutics. The press release can be found here.
Outpatient anticoagulation therapy, i.e. warfarin management, became a big deal when JCAHO made it one of their national patient safety goals a few years back. I’m specifically referring to National Patient Safety Goal 3E: Reducing Harm from Anticoagulation Therapy. If you feel like giving yourself a headache you can read through the entire Abulatory Health Care National Patient Safety Goals (PDF). I wouldn’t recommend it.
(more…) -
Cool Technology for Pharmacy – The Pill Timer
I came across a Tweet mentioning The Pill Timer from Med Time Technology, Inc quite a while back. I would like to give credit to the person that brought it to my attention, but several thousand Tweets have zoomed past my eyes since then. My plan was to purchase one, as they’re only $4.95, and play with it before posting about it. Unfortunately I never got around to it.The Pill Timer is an electronic prescription vial cap designed to provide patients with audio and visual alerts when it’s time to take their medication. Medication adherence is a big problem here in the United States and anything that has the potential to improve compliance is worth a look. I’ve posted on technology like this before, but I believe The Pill Timer is easily the least expensive and simplest alternative I’ve seen. The instructions are relatively easy to follow, and anyone using The Pill Timer should have it programmed and ready for use in no time at all. The instruction sheet can be found here.
(more…) -
Why automated medication kiosks could be good for pharmacy practice
I followed a little banter on Twitter this weekend regarding the use of automated dispensing kiosks to dispense medications to patients instead of using a physical pharmacy. There are many pharmacists out there that believe the use of automated medication dispensing in the outpatient arena is bad practice and separates patients from their pharmacists. I don’t share their sentiment. I’ve blogged about these devices before, here and here, and believe they could be used to improve the pharmacist-patient interaction. I actually had the opportunity to watch an InstyMeds Prescription Medication Dispenser in action under a physician dispensing model late last year and thought it was well done.
It is unclear to me why pharmacists fear these machines, but it reminds me of the fear surrounding automated dispensing cabinets during their inception back in the day.  Now they’re an integral part of acute care pharmacy practice. Perhaps pharmacists believe that patients won’t get the necessary consultation and instruction that they would had they visited their local retail pharmacy. As one that has worked in a retail pharmacy environment, albeit briefly, I don’t buy into that belief. Under the right set of circumstances, and with thoughtful implementation, kiosks could free up pharmacists to spend more time with patients in emergency departments and urgent care clinics across the country. After all, don’t pharmacists argue for more clinical face time with patients and less association with the physical medication dispensing process? That’s what I’ve been hearing from pharmacists for years.
I would argue that placing kiosks in certain locations could improve medication therapy management and patient compliance. The odds of a mother with a tired, cranky, ill child going out of her way to visit a local retail pharmacy at midnight is much lower than grabbing a prescription at an automated dispensing machine in the urgent care clinic following the child’s exam. It certainly couldn’t hurt. Now throw in a consultation from the pharmacist prior to going to the medication kiosk and you have a winning combination.
Kiosks certainly wouldn’t fit every situation, but there is certainly room in the pharmacy practice model for their thoughtful use. Think about it.
-
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.â€
(more…) -
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.
(more…) -
Cool Technology for Pharmacy – MedReady
Medication compliance was an issue long before I became a pharmacist, and it will continue to be that way until the end of time. Some patients chose not to take their medication, while others simple can’t remember, and still others may be willing to take their medication but can’t for one reason or another. The impact of medication noncompliance on healthcare is staggering. Depending on the reference used, the cost of medication noncompliance can run into the billions secondary to hospital admissions caused by treatment failure.The MedReady system is a solution that can effectively help those with bad memories stay compliant. The small, smoke alarm looking device is designed to hold up to 28 separate medication doses with frequencies up to four times a day.
(more…) -
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.
(more…)
