Jerry Fahrni

Tag: Patient Safety

  • Saturday morning coffee [February 21 2015]

    “An error doesn’t become a mistake until you refuse to correct it.” – Orlando A. Battista

    So much happens each and every week, and it’s hard to keep up sometimes. Here are some of the tabs that are open in my browser this morning along with some random thoughts….

    The mug below was sitting next to my laptop filled with chocolate covered espresso beans last Saturday morning, Valentine’s Day. A gift from my lovely wife. Apparently she’s aware of my addiction. It made me smile.

    MUG_Valentines
    (more…)

  • Saturday morning coffee [January 31 2015]

    “Fast is good, accurate is better.” – unknown

    So much happens each and every week, and it’s hard to keep up sometimes. Here are some of the tabs that are open in my browser this morning along with some random thoughts….

    MUG_SMC
    (more…)

  • Cool Pharmacy Technology – Intelliport Medication System

    I briefly mentioned the Intelliport Medication System from BD in a previous post. The technology and potential use cases are impressive.

    The BD Intelliport System offers:

    • Drug and concentration information is presented to the user via audio and visual feedback. The system pulls information from the bar code on the syringe as it’s inserted into the Intelliport injection port.
    • Drug identification, dose measurement and drug allergy alerts in real-time. The allergy information is pulled directly from the patient’s EHR record.
    • Automated documentation of medication delivery. The system wirelessly captures drug, dose, time, and route of administration. The information is fed directly back into the EHR

    Check the video below, it’s really cool.

  • Making the case for bar code medication preparation (BCMP) in sterile compounding

    The tragic death of a hospitalized patient in Oregon [1] has once again put a spotlight on pharmacy i.v. rooms. Unfortunately this isn’t the first i.v. error to harm, or kill a patient and I’m sad to say that it probably won’t be the last. We know that IVs present higher risks than most other medications and the literature presents abundant evidence of the prevalence of pharmacy compounding errors which result in patient harm or death.2-11

    According to a 1997 article by Flynn, Pearson, and Baker: A five-hospital observational study on the accuracy of preparing small and large volume injectables, chemotherapy solutions, and parenteral nutrition showed a mean error rate of 9%, meaning almost 1 in 10 products was prepared incorrectly prior to dispensing.6

    The inherent problem with compounded sterile products (CSPs) is that the efficacy of IV medication administration hinges on the integrity of dose preparation and labeling in the pharmacy. If an item is compounded incorrectly in the pharmacy, no amount of verification at the bedside will alter that. Other than looking at an IV bag or syringe to ensure that no gross particulate matter is present, without chemical analysis it is impossible to verify the contents. Occasionally a color change will acknowledge the addition of the correct additive – yellow multivitamins, red doxorubicin, and so on – but even then, the correct amount (volume/dosage) cannot be verified.
    (more…)

  • ISMP responds to deadly drug error in Oregon

    Last week I wrote about the tragic death of a patient caused by a drug error (CSP error results in death of a patient). One day later on December 18, 2014, ISMP also addressed the error in the Acute Care edition of their biweekly ISMP Medication Safety Alert, i.e. one of their newsletter. I had hoped that ISMP was going to provide much greater detail and insight into the error, but that’s not the case. At least not at this point, anyway.

    I had hoped to find out what occurred in the pharmacy to allow such a mistake to happen. Perhaps more details will come to light as time goes on. All we can do is wait.

    With that said here are some things from ISMP worth noting:

    “To prevent inadvertent use, identify neuromuscular blockers available within your organization and where and how they are stored. Regularly review these storage areas, both inside and outside of the pharmacy, including agents that require refrigeration, to consider the potential for mix-ups.”

    “Limiting access to these products is a strong deterrent to inadvertent use. Consider limiting the number of neuromuscular blockers on formulary, and segregate or even eliminate storage from active pharmacy stock when possible.”

    “Restrict storage of paralyzing agents outside the pharmacy and operating room by sequestering them in refrigerated and nonrefrigerated locations.”

    ISMP recommends highly visible storage container for neuromuscular blockers (one example here: www.ismp.org/sc?id=458).**

    ISMP recommends affixing warning labels on vials and admixtures that clearly communicate the dangers of neuromuscular blockers.**

    ISMP recommends the use of IV workflow technologies. “Now is the time for hospital leadership to support the acquisition of IV workflow technologies that utilize barcode scanning of products during pharmacy IV admixture preparation.” While the article lists only three systems, there are several on the market [see  In the Clean Room TOC for a current list of many of the available systems].

    ————————————-
    **I know that many think this is a good idea, but I’m not so sure that I’m one of them. On the surface, using highly visible storage containers and labels might seems like a good idea, but over time people become used to the idea and become blind to the differences. In addition, over the years the number of items that require alternate storage and labeling has grown, making differentiation “the norm”. It’s like the student that highlights everything in the textbook with five different colors. Eventually the entire book is highlighted, making the process meaningless to the reader.

  • CSP error results in death of a patient

    A 65-year-old woman died at St. Charles Medical Center in Oregon after being given an infusion of rocuronium instead of fosphenytoin.

    “The prescription was entered correctly into the electronic medical records system, and the pharmacy received the correct medication order, the AP reported. The IV bag was also labeled properly. After the pharmacy worker mistakenly filled Macpherson’s IV with rocuronium, a second employee did not catch the error while checking the vials of medication and the IV bag for the 65-year-old patient.” (via: Pharmacy Times).

    As details of the tragedy continue to emerge, here’s what we know so far:

    • An infusion of fosphenytoin was ordered for the patient, presumably a piggyback.
    • Instead of fosphenytoin (anti-seizure med) the patient received rocuronium (a paralytic)
    • It is unclear at what point in the compounding process, if at all, the infusion was verified by a pharmacist. According to the article “a second employee did not catch the error while checking the vials of medication and the IV bag”. Not entirely sure what that means.
    • The infusion was hung
    • A fire alarm sounded
    • The nurse closed the patient’s door and didn’t check on her for 20 minutes. That was more than enough time for the drug to cause irreparable harm to the patient.

    It is unclear what process was used to make the infusion, or what safety safeguards were in place. The real shame here is that there are any number of available technologies that could have prevented the error. Any of the semi-automated workflow management systems on the market today would have worked. Bar code scanning, gravimetrics, perhaps image assisted verification, etc. Take your pick.

    According to an article from The Bulletin “To help prevent similar mistakes from happening, the hospital’s pharmacy has begun placing orange stickers on IV bags containing paralytic agents that indicate what’s in them. [The patient’s] IV bag had a blue sticker indicating it was a neuromuscular agent, which Boileau [Dr. Michel Boileau, St. Charles’ chief clinical officer], said both fosphenytoin and rocuronium are.” Not exactly sure how using orange stickers instead of blue is going to do much. Seems kind of silly. I think I’d start looking at something a little more aggressive. I’d also rethink my classification of both fosphenytoin and rocuronim as “neuromuscular agents”. I think I’d call fosphenytoin a hydantoin anticonvulsant and rocuronium a nondepolarizing neuromuscular blocker. They’re clearly not the same class of drug.

    It will be interesting to see how organizations like ISMP and ASHP respond to this latest error.

  • Saturday morning coffee [December 13 2014]

    “A doctor who works without error is not a genius. He is a liar.” ~unknown

    So much happens each and every week, and it’s hard to keep up sometimes. Here are some of the tabs that are open in my browser this morning along with some random thoughts….

    MUG_SMC
    (more…)

  • #ASHP Midyear 2014 update

    I spent several hours in the exhibit hall yesterday trying to make my way through my proposed “game plan”. Didn’t even get close. I kept getting sidetracked by one thing or another.

    Stops I did make were all interesting, and included:
    (more…)

  • In the Clean Room: A Review of Technology-Assisted Sterile Compounding Systems in the US [report]

    For the better part of the past year I’ve been working on a project with Mark Neuenschwander of The Neuenschwander Company looking at technologies used in pharmacy clean rooms to prepare sterile compounds.

    The research into this area took much longer than originally anticipated. We discovered along the way that this subject is much more complex than it appears on the surface. Information is difficult to find, some of the technologies are little more than marketing material on a company website, and the subject matter is in its infancy.
    (more…)

  • The illusion of multitasking

    Yesterday I went through the drive-thru of a local fast food chain. The young lady manning the register asked for my order, so I started giving it to her. She asked me to pause for a second, and when she resumed she repeated the first part of my order back to me. She had it completely wrong. This happens to me all the time in the drive-thru, which is why I typically avoid them at all cost. Yesterday I made an exception and instantly regretted it.

    People working drive-thru windows at fast food joints typically try to multitask, i.e. take an order from one person while trying to put an order together for another, and so on. In my experience this usually results in what happened to me yesterday. Frequently I have to repeat part, if not all, of my order. I find it quite irritating.

    Multitasking is a myth, plain and simple. People do not have the mental capacity to concentrate on more than one thing at a time. Don’t take my word for it. There’s plenty of evidence to back up my claim.

    Christopher Chabris, PhD is a professor, research psychologist, and coauthor of the best-selling book The Invisible Gorilla. His research focuses on two main areas: how people differ from one another in mental abilities and patterns of behavior, and how cognitive illusions affect our decisions. He has published papers on a diverse array of topics, including human intelligence, beauty and the brain, face recognition, the Mozart effect, group performance, and visual cognition. He was also the keynote speaker at the unSUMMIT that I attended last week. The presentation was fantastic.

    According to Dr. Chabris everyone thinks they can multitask, but very few can. His research estimates that a mere 2.5% of people can “do ok as a multitasker”. Unfortunately his research has demonstrated that everyone thinks they can multitask, and those that consider themselves true multitaskers tend to do the worst in experiments that require one’s attention.

    Everything that Dr. Chabris spoke about applies to pharmacy, but I found two things particularly interesting:

    • Post completion errors – this is when someone forgets to complete the last step of a process. Examples include leaving an original paper on a copy machine, or in healthcare, when someone leaves the guide wire from a PICC insertion in place. Even when people are told they forgot the final step they often can’t figure out what went wrong. Dr. Chabris refers to this as “satisfaction of search”, i.e. you see what you expect to see. This type of thing happens all the time in pharmacy practice, especially during the distribution process and the IV room.
    • “Illusion of attention” – this is when people think they can pay attention to multiple things at once. He refers to this as an “everyday illusion”, of which multitasking is a prime example. These misconceptions are hard to overcome and systematically wrong. How many times have you witnessed a pharmacist or pharmacy technician trying to do more than one thing at a time – talk on the phone while filling a script, retrieve tablets from a “Baker cell” while on the phone, etc? Happens all the time.

    Overall the presentation was solid and the information valuable. I recommend taking a look at Dr. Chabris’ work. The concepts can be applied both directly and indirectly to errors that occur in the pharmacy.