Jerry Fahrni

Tag: Patient Safety

  • 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.
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  • “What’d I miss?” – Week of October 24, 2010

    As usual there were a lot of things that happened during the week, and not all of it was pharmacy or technology related. Here’s a quick look at some of the stuff I found interesting.
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  • Pharmacovigilance, what’s in a name

    I read an interesting discussion about pharmacovigilance (PV) software a few weeks ago on one of the pharmacy listservs I belong to. The conversation struck me as odd because much of it sounded an awful lot like a discussion on clinical decision support (CDS). This led me to wonder whether or not PV and CDS are the same thing, completely different or subsets of one another. I am not familiar with the term PV myself, so I set out to gather some information. And here’s what I found.
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  • 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 appetite”. 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.
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  • More problematic barcodes

    Recently I’ve heard of hospitals having problems with barcodes on pre-mixed IV bags. The problem isn’t related to the legibility or quality of the barcodes, but rather the location and/or the information contained within the barcode itself.
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  • RFID still a solid alternative to barcoding

    There’s an interesting article in the most recent issue of Patient Safety & Quality Healthcare (PSQH) about the use of RFID technology in healthcare and what advantages it may offer over current barcoding technology.

    I’ve been interested in the use of RFID technology in healthcare for quite some time. I think there’s real value in the use of RFID secondary to the ability to encode significant amounts of information in the tag. The information contained in an RFID tag could potentially include a patient’s medication regimen, allergies and medical condition. The value become obvious when you consider the possibilities during medication administration in the acute care setting.
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  • Beyond the idea of a medical-alert bracelet with the use of text messaging

    I stumbled across an article in The Wall Street Journal that discusses the use of advancing technologies to improve first responder access to important patient information. Anyone that has a severe allergy or that requires special treatment for a rare or life threatening medical condition is probably aware of medical alert bracelets. Order forms for these trinkets are prevalent in pharmacies across the country. Well it seems that the idea of medical alert bracelets is starting to take on a more technologically advanced edge like everything else in healthcare these days.

    One of the things that caught my eye in the article was the mention of a program called Invisible Bracelet (iB) that utilizes text messaging to retrieve pertinent medical information about a patient, while at the same time notifying the patient’s emergency contact(s). And since I was just talking about using text messaging as a way to improve patient compliance with medications I thought it was worth a closer look.

    “The program, a partnership between Docvia LLC of Tulsa, Okla., and the American Ambulance Association, a trade association, allows members for $10 a year to upload personal medical data to a secure website and receive a personal identification number. Members get cards to place behind their driver’s license, key fobs and stickers that can be put on, say, a bike helmet that show their identification number and the website address.

    The program is currently available in a dozen markets and is expected to expand. Docvia trains ambulance medics to use the system. The website also allows medics to automatically generate text or email messages to designated family members notifying them where the patient is being taken by ambulance.”

    Neat concept.

  • It may be time to consider robotic IV preparation at the bedside

    Hospitals make a lot of intravenous (IV) preparations. That makes sense when you consider that most people admitted to the hospital are there because their acute illness requires more care than can be administered at home; not always, but in most cases. This is especially true for patients in the intensive care unit, i.e. the ICU.

    A fair number of the medications used in the ICU are prepared on demand for a host of reasons including stability, differences in concentration, difficulty in scheduling secondary to rate variability, etc. Any pharmacist or nurse reading this will understand what I’m talking about. Example medications that fall into this category include drips like norepinephrine, epinephrine, phenylephrine, amiodarone and nitroprusside.

    Last year I mused about using devices on the nursing stations designed to package oral solids on demand at the point of care. I still like the idea for several reasons, all of which can be found in the original post.  Based on currently available technology the same concept could be applied to preparation of IV products at the bedside. Robotic IV preparation has come a long way and these devices could be used at the point of care to make a nurses, and patient’s, life a whole lot easier. The use of robotic IV preparation at the bedside could reduce wait times for nurses and lesson the workload on pharmacy.
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  • 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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