Thoughts on my time with DoseEdge Pharmacy Workflow Manager 

Yesterday, I had a great opportunity to spend the day using DoseEdge in its native environment. That is to say, I staffed at a facility that was using DoseEdge in its cleanroom to prepare CSPs, including patient-specific products as well as stock bags, TPNs, etc. I’ve used DoseEdge for brief periods in the past. I’ve also spent time with the engineers that have worked on the product, product managers, sales people, marketing folks, and various other Baxter employees at conferences like ASHP midyear. But, this is only the second time that I have worked an entire  “staff pharmacist” shift using the product. And as one might imagine, using a system in its native environment can often provide a new perspective.

DoseEdge System at Boston Children’s Hospital

I’ve written about DoseEdge, and systems like it, extensively on this site over the years.  A quick search of jerryfahrni.com revealed several articles mentioning DoseEdge, dating back to 2010. I’ve also written about DoseEdge and similar products extensively elsewhere.

With over 300 installs in the U.S., DoseEdge is one of the most popular IV workflow management systems on the market and is still the most widely implemented product of its kind in the U.S. It’s a very good system, certainly in my top five. There are several things that I really like about the system, such as how it controls labels, its ability to track partial vials, and the fact that it talks. Seriously, it speaks to the user. Pretty cool.

However, there’s always room for improvement. For example, after using the system, I found that I don’t really care for the user interface (UI). I found it to be rather unintuitive and a bit clumsy. The UI is stuck somewhere between a legacy system and a modern web-based system. It’s not good. Too many clicks, things in weird places, naming conventions that simply don’t make sense in my mind, just to name a few. With that said, it’s still quite usable, and honestly, it’s likely as good as any other UI on any other product that I’ve used in the pharmacy.

The other thing that hit me yesterday was just how terrible the process of using images is to verify the accuracy of compounded products. I don’t care for it. As good as the images are – and they’re quite good in DoseEdge – there are still shadows in strange places that make reading syringe volumes difficult at times. This is especially true for small volumes. There were times yesterday when I simply made educated guesses to the exact volume and assumed that the volume was accurate, as I couldn’t quite see the exact location of the plunger. Don’t get me wrong, this is still way better than the syringe-pullback method, but image-assisted verification isn’t optimal. I would have liked to have had the gravimetric option available to me yesterday. DoseEgde offers gravimetrics, although it isn’t widely used.

So, good system, but not perfect. Better than the manual process, but room for improvement. Imaging better than pullback, but not great.

ISMP releases new medication safety best practices document

I quite literally stumbled across this the other day while doing research for another project. I heard that ISMP had updated their best practices document, but didn’t see an official announcement. It’s possible I just missed it.

ISMP_Best_Practices

The document contains some great new safety recommendations. All in all there are eleven best practices listed. Most of the recommendations are what I would consider minor, but there are a couple that I think are worth highlighting:

Dispensing vinCRIStine in a minibag instead of a syringe. This is one of those ideas that seems so simple, yet brilliant. When you read it, you instantly say to yourself “why didn’t I think of that?”. VinCRIStine is commonly dispenses in a syringe and given via short IV push. However, being dispensed in a syringe has led to the accidental administration of the drug via the intrathecal route. The result is devastating neurological damage, up to and including death. By simply putting the drug in a minibag, you effectively eliminate the possibility of it being administered intrathecally.

Performing independent verification of ingredients during sterile compounding. This includes a recommendation to use technology to “assist in the verification process (e.g., barcode scanning verification of ingredients, gravimetric verification, robotics, IV workflow software) to augment the manual processes.” I believe this is the first official document from an organization to include such a recommendation. Congratulations to ISMP for having the resolve to do this. ASHP needs to follow suite.

More information can be found here: 2016-2017 Targeted Medication Safety Best Practices for Hospitals [PDF]

Microneedle patch for monitoring drug levels

Medgadget: “A collaboration between researchers at the University of British Columbia and Paul Scherrer Institut in Switzerland has developed a microneedle device for drug monitoring. The device is in a form of a patch that’s stuck onto the skin, painlessly pushing microneedles through to sample the interstitial fluid…The proof-of-concept device reported by the team was used to measure the concentration of vancomycin.”

microneedle-optofluidic biosensor

This is something that has been sorely needed for a long time. As a pharmacist, I can confidently state that we spend entirely too much time looking at drug levels that are within normal limits versus evaluating those that are not. It would seem much more efficient, at least in the acute care environment, to ignore “normal” levels and spend our time investigating those that are out of whack.

In the outpatient environment this makes even more sense as a patient safety measure. Imagine never again having a patient urgently admitted to the hospital for a drug level that’s way too high. Think of all the medications that require at least intermittent drug levels: carbamazepine, phenytoin, digoxin, tacrolimus, and so on.

Side note, my mother was taking tacrolimus around the time of her liver transplant. An EHR charting error occurred that resulted in her receiving 10 mg orally twice a day instead of 1 mg orally twice a day; yep, a 10-fold error. True story. Almost killed her. The small-town hospital where she lived didn’t recognize the symptoms and failed to get a drug level when she was admitted for “dehydration”. Several days of pleading with physicians and calls to UCSF resulted in a level being drawn. It was off the charts. She was subsequently transferred to UCSF where she spent the next six weeks in the ICU. The entire ordeal could have been avoided with real-time drug monitoring. Just sayin’.

Mobile health apps not meeting expectations

I read with great interest a recent piece at FierceHealthcare. According to a study in the Journal of General Internal Medicine, health apps aren’t living up to the hype. To me, the entire field has been overblown from the beginning.

“A new UC San Francisco study … revealed nearly every participant who used health apps could not get to a productive point. The respondents also were able to complete just 51 percent of data entry tasks and just 43 percent of them could access data from the tools.”

Most of the problem stemmed from usability, or rather a lack thereof. This should come as a surprise to no one. Most of the health apps that I’ve tried haven’t been very good. In fact, I have yet to find a single health app that I consider anything more than a waste of time.

All this on the heels of other studies showing similar results. “A study released in mid-June noted very few apps providing high-quality heart failure symptom monitoring. Research earlier this month evaluated 40 fertility and pregnancy apps and found just six recorded a perfect score for accuracy.”

While I understand the desire for mHealth to be a success, at this point I believe it’s nothing more than over-hyped mediocrity. The worst part is the number of app developers and “researchers” taking advantage of the situation to further their own career, or in some cases their agenda. The mHealth movement is full of snake oil salesmen taking advantage of a population desperate for help.   As a healthcare provider myself, I find it hard to believe that other healthcare providers are putting so much stock in so little actionable information. Does that mean that all mHealth applications are useless? Probably not, but I think it’s time to step back and take a long, hard look at the entire ecosystem. The first thing we should be asking is whether or not the information being collecting provides any value to the patient or their provider. If not, I think it’s fair to question whether or not the application should even be available.

As a healthcare provider myself, I find it hard to believe that other healthcare providers are putting so much stock in so little actionable information. Does that mean that all mHealth applications are useless? Probably not, but I think it’s time to step back and take a long, hard look at the entire ecosystem. The first thing we should be asking is whether or not the information being collecting provides any value to the patient or the provider. If not, I think it’s fair to question whether or not the application should even be available.

Now I’ll sit back and wait for the onslaught of people telling me how wrong I am. Obviously I “just don’t get it”. Well, remember this, even homeopathy has supporters. Just sayin’.

Prescription bottle innovation

I was browsing for something the other day and got sidetracked by a link about prescription bottles. You know how it is, you start scouring the internet for information on antibiotic dosing in CRRT and end up looking at cat videos. It happens.

Anyway, I think it’s safe to say that everyone has seen a prescription bottle. Those cylindrical amber bottles with white caps that are almost universally used by pharmacies everywhere. Oh sure, there are minor variations here and there – like blue bottles, for example – but for the most part, they’re pretty standard across the board. In fact, you probably have a few strewn around the house in the “medicine cabinet”, in a handbag, or thrown in a drawer somewhere.

Rxbottle

Do you ever wonder why they look the way they do? I have, but never really cared enough to look into it. Until now, that is. Cat videos, remember?

Apparently, prescription bottles as we know them today were introduced sometime in the 19th century. They weren’t always cylindrical. Some of the early designs were actually rectangular. The rectangular brown wide-mouth bottle can still be found in the wild, but you don’t see them often. They’re really cool, but are made of glass and cost significantly more than a $0.01 amber plastic vial.

Prescription vials are colored to prevent light from damaging light-sensitive drugs. Are all drugs light sensitive? No, but it doesn’t make sense to have different bottles for different drugs. Does it have to be amber? No, but I read somewhere that amber is the most cost-effective color. I don’t know if that’s true, but it would make sense as to why we don’t see more color options. Why not use a solid material, i.e. one you can’t see through, to prevent light from coming through the bottle? Fair question. My guess is because the semi-transparent nature of today’s prescription bottle allows you to see the contents without having to remove the lid. However, when looking at the contents of a prescription vial, I always remove the lid to evaluate the color and condition of the contents.

That’s the nuts and bolts of the modern prescription vial. There’s a lot more history if you’re interested. For those of you that crave a deeper, more detailed history of the prescription vial, I direct you to History of Drug Containers and Their Labels by George Griffenhagen and Mary Bogard. Real page-turner, that one.

Knowing that modern prescription bottles have been around for more than 100 years, one has wonder why we haven’t seen more innovation. Is it because they’re perfect? Doubtful. More likely the lack of innovation has been due to complacency.

With that said, there have been a couple of advancements in recent years. One high-tech solution, and one not so high-tech solution.

AdhereTech introduced a “modern” prescription bottle several years ago. I wrote about their bottle design back in 2013. Since that time, the company has introduced a new bottle design, which by the way is similar in size and shape to the brown wide-mouth bottles mentioned above. The new bottle can be seen in the image below. It’s unclear to me what made them alter the design. I’ll have to do some digging.

Adheretech

The second, more low-tech innovation comes from Target of all places. The retail giant introduced the ClearRx bottle more than ten years ago. You can read more about the ClearRx bottle/system at the ISMP site here. The bottle has a rather impressive design. It’s simple yet elegant. However, it’s unclear whether or not Target continues to use this bottle since being acquired by CVS. I guess I’ll have to venture out of the house and find out.

ClearRx_bottle

The prescription bottle has a long and rich history but it seems to me that it’s time for someone to come up with something new. With the advent of 3D printing, it shouldn’t be too hard to come up with several potential prototypes in a relatively short period of time. Crud, I have a 3D printer. Can’t be that hard, can it?

Electronic alert overload

The Washington Post: “Something similar is happening to doctors, nurses and pharmacists. And when they’re hit with too much information, the result can be a health hazard… It’s called alert fatigue… Electronic health records increasingly include automated alert systems pegged to patients’ health information… The number of these pop-up messages has become unmanageable, doctors and IT experts say, because of reflecting what many experts call excessive caution, and now they are overwhelming practitioners.”

alert_overrides

I had to laugh when I read The Washington Post article quoted above. Pharmacists have been dealing with this for years. We’ve been getting hammered with unnecessary alerts since electronic order entry became a thing. I don’t know exactly when it started, but it’s been an integral part of my career for the past 20 years.

It’s a problem to be sure. A vast majority of alerts, conservatively 90%, have absolutely no bearing on the job clinicians are asked to perform. The article mentions receiving alerts for pain meds when it’s obvious that the patient needs them, such as in a post-op situation. Even more ridiculous is getting an alert for a duplicate fluid, or my favorite, lactation warnings for an 80-year-old female.

It’s difficult to say what the impact of these alerts is on patient care, but I think it’s safe to say that they cause more harm than good. They pop up so often that most simply get ignored. I know that I’ve clicked through my fair share of alerts without more than a glance.

And here’s the thing, physicians see only a fraction of the alerts seen by pharmacists. Many hospitals minimize alerts so as not to irritate physicians. We wouldn’t want to irritate physicians now, would we?

With all that said, things have improved in the past few years. Usability is on the radar of hospitals and healthcare systems. We can thank consumers for that. Healthcare workers are consumers first and their experience with software and hardware in their day-to-day lives has spilled over into healthcare. Today’s software is much better than it was a decade ago, even in the Bizzaro World of healthcare.

I can recall my experience with pharmacy information systems during the early years of my career. They were terrible, and I do mean terrible. The things were barely usable. They were often functionally rich and usably poor. It wasn’t until quite recently that pharmacy systems became more user-friendly, in part because of the introduction of EHRs.

Physicians wield a disproportionate amount of power within healthcare systems, so when they are forced to use EHRs with poorly designed user interfaces and ridiculous alerts, the vendors hear about it. The result of all that complaining has been improvements in usability. As the pharmacy system is an integral part of many EHRs, pharmacists have benefited.

I dare say that we are nowhere near the user experience of consumer products, but the improvements are nonetheless welcome. Given time, and enough physician whining, we may live to see the day when alerts are useful rather than annoying. Until then, I say to my physician brothers and sisters, welcome to my world.

The scope of IV room errors

There’s an interesting article in Pharmacy Practice News this month (In the IV Room, Robots Come to the Rescue). While the title of the article is a bit misleading – I think ‘rescue’ is a bit strong – it does contain quite a bit of good information.

The article discusses some of the technology being used at Brigham and Women’s Hospital (BWH) in Boston, and the University of California, San Francisco (UCSF) Mission Bay pharmacy. I’ve been in both pharmacies. BWH and UCSF both make extensive use of technology, but believe me when I say that they have very different approaches. Anyway, the article is worth a few minutes of your time.

Deep in the article, the author, Rajiv Leventhal spends a few paragraphs discussing the scope of the problem in the IV room, and some of the challenges of using robotics. Rajiv acknowledges that the iv room is a dangerous place for a host of reasons.

Regardless of the technology chosen, the need to automate IV compounding to at least some degree is hard to dispute, given the relatively high rate of errors that occur when technology is limited. In 1997, when many of the recent advances in robotics were not available, the error rate for IV compounding was 9%—or one mistake in every 11 medications coming out of the IV room.

As for the main cases [sic] of those errors, many factors have been identified, including sterility and other drug safety issues, according to a safety alert released last year by the Institute for Safe Medication Practices. The alert identified five core causes: 1) depreciating importance of the compounding and dispensing processes in pharmacy practice; 2) lack of knowledge and standardization around best practices; 3) training based on traditions handed down from one pharmacist to the next; 4) learned workplace tolerance of risk and routine practice deviations that persist; and 5) a reluctance to learn from the mistakes of others.

It seems intuitively obvious that the use of technologies like iv workflow management software, barcode scanning, gravimetrics, imaging, and even robotics can potentially decrease errors described in the article referenced above (Am J Health Syst Pharm1997;54[8]:904-912 ). However, of the causes identified in the second paragraph, only #2 can really be addressed with the use of technology alone. The rest of the items listed are symptoms of a deep-seeded problem growing in pharmacies today, and that is the failure to understand the need for our profession to provide patients with medications in the most efficient, safe, and economical way possible. Sounds ridiculous, I know, but it’s true nonetheless.

Most (all?) pharmacies I visit these days tout initiatives to improve patient care through increased ‘clinical activities’ of pharmacists, including electronic chart review, ADE follow-up, rounding with the medical team, monitoring and adjusting medications, antibiotic stewardship, and so on. However, I rarely, if ever hear directors talk about efforts to improve operations through streamlined processes, automation and technology, standardization, and heaven forbid, increased use of technicians and non-pharmacist personnel.

Examples of this can be found within open job listings at various healthcare systems. Recently I visited an acute care pharmacy with a large budget for several open ‘clinical pharmacist’s positions’ but no budget for improving operations or automating processes. In this particular case, a fraction of the money being allocated for open clinical pharmacist positions could be used to make significant improvements to the medication distribution process.

It’s an interesting dilemma for pharmacy directors. While spending tens of thousands of dollars on automation and technology to improve operations may not seem sexy, it goes without saying that a vast majority of care for a hospitalized patient involves getting the right drug at the right time. A majority of that falls to nursing staff, but the pharmacy owns a piece of the medication distribution/administration process. Nurses can’t administer medications if they’re not readily available, or wrong.

Regardless of what direction the profession wants to go, it is important that we understand that pharmacy is, at this time, tied to distribution. We must find ways to extricate ourselves from the medication distribution process first before we can begin to truly realize the benefits of pharmacists in patient care. Each time an error occurs for lack of focus, training, or sheer disinterest, the profession suffers. Preventable medication errors involving the pharmacy causes both the public and other healthcare practitioners to lose trust in our ability to get the job done. It’s difficult to recover from lack of trust. Think about it.

JerryFahrni.com Podcast | Episode 12: Pharmacy IV room discussion with Ray Vrabel, PharmD

Show Notes:
Host: Jerry Fahnri, Pharm.D.

Jerry and Ray talk about the pharmacy IV room, specifically where we’ve been, where we’re at, and where we’re headed. Topics include workflow, the impact of USP <797> on pharmacy iv room operations, and thoughts on currently available iv workflow management system technologies.

You can learn more about Ray at his LinkedIn Profile here.

Items discussed in podcast:
Current setup:
Blue Microphones Yeti USB Microphone – Blackout Edition
Dragonpad Pop Filter
Sony MDR-V150 Headphones

Frequency of and risk factors for med errors during order verification

error

A friend and colleague of mine and I were talking about pharmacy order verification and errors the other day.

Many (all?) acute care pharmacies use the number of orders entered/verified by pharmacists per unit of time as a performance metric. The theory being that the more orders you verify the busier you are and therefore the more work you do. Sounds logical. And it is. And it also isn’t. It is because more orders typically equates to a heavier patient load and/or sicker patients, which in turn results in more work. It isn’t because some orders – and the associated distribution of medications associated with those orders – are significantly more complex than others. Chemotherapy is a good example of this. The amount of work required to verify and dispense your average chemotherapy order is several orders of magnitude greater than an order for, oh I don’t know, a saline-lock.

So in theory, a pharmacist verifying more chemotherapy will certainly have lower numbers than a pharmacist verifying routine medication orders. However, when evaluating the number of orders verified over an entire year, one would expect the number of complicated orders handled per pharmacist to average out over the long haul. That’s not complicated math, just common sense.

Assuming that every pharmacist is on equal footing, and that the number of orders verified is a reasonable performance metric, what then is a reasonable number of orders to be verified per hour, per shift, or per year to be considered good, bad, or average? It’s impossible to say. One would think that the higher the number the better the productivity. Here’s the thing, during periods of high volume order verification, pharmacists make more mistakes. Not just mathematically more, i.e. 1% of 300 is more than 1% of 200, but a higher percentage of mistakes.

From a blog post at the American Pharmacist Association (APhA) website: “the number of medication errors increased with the number of orders verified per pharmacist per shift” … According to the findings, the verification of more than 400 orders per shift per pharmacist was associated with the highest risk of errors…“Once we got to the 400 mark, meaning 400 orders verified per pharmacist, [we] started to reach a higher number of errors,” said Christy Gorbach, PharmD, coauthor of the study“. The study referred to in the APhA post is this one.

So it would appear on the surface that using volume of orders verified as a performance metric is actually driving pharmacists to make more mistakes, thus leading to less productivity, not more. (1)

With the increased adoption of EHRs, the number of orders verified per pharmacist is only going to grow. EHRs have made order entry quick and easy. Physicians create lists – favorites, order sets, etc. – that allow them to simply check a box and put patients on multiple medications in a matter of seconds. This is especially true for what I refer to as “don’t-call-me” orders. Don’t-call-me orders consist of multiple PRN medications to cover everything from fever to constipation; all designed to prevent the physician from receiving a phone call at 3 o’clock in the morning, i.e. don’t call me. Most of these orders go unused and simply complicate the medication profile and medication administration record.(2) Verifying such a large number of redundant, benign orders creates alert fatigue and selective blindness which ultimately leads to something important getting missed.

All in all, the results are increased verification numbers, more work, and as it turns out, more errors. Unfortunately, I have no answer to the problem. And make no mistake, it is a problem. Orders have to get verified and released, and patients must receive their medications in a timely manner. With that said, safety must also be a top priority. Medication errors are unacceptable.

Overall, it appears that using volume of orders verified by a pharmacist as a performance metric is a bad idea. I think it’s time to slow down, pay attention, and create an environment that rewards pharmacists for the quality of their work, not for the speed at which they perform it.

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  1. Medication errors can lead to all kinds of problems, among them wasted time.
  2. All the pharmacists reading this are shaking their head and grinning because they know exactly what I’m talking about. What pharmacist hasn’t seen a post-op C-section order with 15 to 20 PRN medication orders, including half a dozen different pain meds that never get used? It happens all the time.

Novel formulation of ethanol for glove decontamination to prevent Clostridium difficile contamination

Clostridium difficile is a major problem in hospitals across the U.S. According to the CDC, it is estimated that C. difficile caused almost half a million infections in the U.S. in 2011, and approximately 83,000 of the patients who developed C. difficile experienced at least one recurrence and 29,000 died within 30 days of the initial diagnosis.  Staggering numbers.

C. difficile is a nasty spore-forming bacteria that produces toxins. The main clinical symptoms of C. difficile infection include watery diarrhea, fever, nausea, abdominal pain, and loss of appetite. More serious infections can result in pseudomembranous colitis, perforations of the colon, and in extreme cases sepsis.

For the reasons cited above, I found this Pharmacy OneSource article quite interesting. According to the OneSource article: “A concise communication recently published in the Infection Control & Hospital Epidemiology (ICHE) journal provides effectiveness data on a novel formulation of ethanol used for glove decontamination to prevent Clostridium difficile (spores) hand contamination during glove removal… Test solutions included the novel, sporicidal ethanol formulation (70% ethanol adjusted to pH 1.3 with hydrochloric acid), as well as, 1:10 and 1:100 dilutions of sodium hypochlorite (bleach), and 70% ethanol with no pH adjustment/additives… [the] sporicidal ethanol formulation was effective in rapidly reducing C. difficile spores by approximately two logs, with a further reduction when applied as a wipe.” This was equivalent to 1:100 dilution of bleach solution.

While there are no studies that I’m aware of linking C. difficile infection to pharmacy cleanroom practices, such a novel anti-C. difficile solution has potential wide sweeping application throughout acute care facilities as well as long-term care facilities.

The abstract for the article cited in the OneSource piece can be found here states: “Decontamination of gloves before removal could reduce the risk for contamination of hands of personnel caring for patients with Clostridium difficile infection. We demonstrated that a novel sporicidal formulation of ethanol rapidly reduced C. difficile spores on gloved hands without adverse odor, respiratory irritation, or staining of clothing.” – Infect. Control Hosp. Epidemiol. 37.03 (2015): 337-339.