Jerry Fahrni

Tag: Patient Safety

  • Pre-packaged unit dose from the manufacture or repackaging yourself?

    Like it or not barcoding at the point of care has slowly become a standard of practice in acute care pharmacies all over the country. The question is no longer whether or not we should use barcoding technology, but rather how do we use it. And with that comes the need to make sure that all medications dispensed from the pharmacy have a machine readable barcode for nurses to scan at the point of care, i.e. at the patients bedside.

    The concept is simple, but causes a lot of headaches inside the pharmacy. While a lot of oral solid medications are available from the manufacture in pre-packaged unit dose packages, some aren’t; sometimes oral solid medications are available in both pre-packaged unit dose as well as bulk.

    When oral solid medications are available in both pre-packaged unit dose and bulk containers pharmacies are forced to make a choice. It’s always been a no-brainer for me, purchase medications in manufacturer prepared pre-packaged unit dose packages whenever possible. I look at it as a safety issue. Humans make mistakes, and whenever I can remove humans from something like repackaging oral solids I do it. Manufacturers have been known to make mistakes, but their process is much more rigorous than anything you’ll see in a pharmacy. In addition, manufacturers must adhere to good manufacturing practices (GMP), which are quite extensive.

    Recently I’ve come across situations where pharmacies have actively chosen to purchase all oral solid tablets in bulk and repackage the oral solids themselves. I’ve thought about why a pharmacy would make that choice and two things come to mind: cost and efficiency.

    Purchasing oral solid medications in bulk is often less expensive. The advantage may be extended if a single location is repackaging for multiple facilities, i.e. centralized distribution. The same goes for efficiency. Repackaging oral solid tablets from bulk bottles may be more efficient during times of high volume, especially if multiple sites are involved. An example of this might be during ADU replenishment for multiple facilities when thousands of tablets may be needed. Picking 2000-3000 tablets from shelving locations may be less efficient than letting a packager run unmanned.

    Options for repackaging oral solid medications:

    1. High-speed packagers – I wrote about high-speed packagers here in August of 2010 (Automated unit-dose packagers for acute care pharmacy). Little has changed since then so the information may still be helpful.
    2. Tablettop packagers (semi-automated) – I wrote about tabletop packagers here early this year in January. (Pharmacy tabletop unit-dose packager comparison). You wouldn’t want to use tabletops for large jobs as they require closer monitoring than high-speed packagers.
    3. Manual packaging – There are several out there. One that comes to mind is MTS. There is no way you’d want to use a system like this for any kind of high volume packaging. They work well for niche packaging like chemotherapy, high risk items, etc.

    The choice to repackage oral solid medications from bulk or purchase them in pre-packaged unit dose packages from the manufacture is yours. Patient safety, cost, and efficiency should all be considered. In my opinion patient safety should trump cost and efficiency in the thought process, but then again that’s only my opinion.

  • Fresh application of older healthcare technology

    I came across an interesting article in the July issue of Pharmacy Practice News. The article describes some of the posters presented at the 2013 ASHP Summer Meeting in Minneapolis. The technology covered is relatively old, and a little antiquated when you look at much of the technology floating around the world these days. Nonetheless, this technology still represents opportunity in healthcare.
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  • Cool i.v. room technology – Drugcam Assist

    [Update 12/22/2013: I received an email from one of the inventors/developers of Drugcam software informing me of a new website that contains more information about the system. The site is eurekam.fr, which contains pages describing both Drugcam Assist and Drugcam Control. It’s still not a great amount of information, but at least it’s more than I had.]

    I’ve talked about technology for the i.v. room extensively on this weblog. It’s no secret that I think the i.v. room is the next frontier for pharmacy technology. The reason I think this is simple, the i.v. room is dangerous, and precious few healthcare systems are using technology to its fullest in that environment.

    I’m not the only one that thinks the i.v. room is important. As of December of 2012 I knew of basically four i.v. room workflow management systems: DoseEdg DoseEdge by Baxa, Pharm-Q In The Hood by Envision Telepharmacy, SP Central Telepharmacy System by ScriptPro, and Phocus Rx by Grifols.

    Joining the fray are at least two more systems that I saw at the ASHP Summer Meeting just last week: Cato software, which is now owned by DB, and Drugcam Assist by Getinge. Unfortunately you won’t find much about Drugcam Assist online, which is really too bad because it’s an amazing system. The website offers more information and a video demonstration for those that are willing to fill out a form and register. I was not willing.

    Drugcam Assist
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  • Clinical Dilemmas and a Review of Strategies to Manage Drug Shortages [article]

    Here’s an interesting article in the Journal of Pharmacy Practice. The article, Clinical Dilemmas and a Review of Strategies to Manage Drug Shortages appears online ahead of print (doi: 10.1177/0897190013482332). Unfortunately you’ll hit a paywall, so if you don’t have a subscription all you’ll get is the abstract.

    That’s unfortunate because according to the article “The expanded phased approach outlined here [in the article] provides a consistent, systematic approach for the management of drug shortages“. You would think they’d want everyone to know about the expanded phased approach due to the “health care crisis” created by drug shortages. Just sayin’.

    Abstract
    ———————————————-
    Objective: The objectives of this article are to review the clinical implications of drug shortages highlighting patient safety, sedation, and oncology and introduce an expanded phase approach for the management of drug shortages. Data Sources: Literature retrieval was accessed through a PubMed search of English-language sources from January 1990 through April 2012 using the medical subject heading pharmaceutical preparations/supply and distribution and the general search term drug shortages. Study Selection and Data Extraction: All original prospective and retrospective studies, peer-reviewed guidelines, consensus statements, and review articles were evaluated for inclusion. Relevance was determined considering the therapeutic class, focus on drug shortages, and manuscript type. Data Synthesis: The increased number of drug shortages has created significant challenges for health care providers. Two particularly vulnerable populations are critically ill and oncology patients. A lack of therapeutic alternatives in critically ill patients may impact patient safety as well as treatment outcomes. Similarly, a chemotherapy agent in short supply may contribute to adverse outcomes in oncology patients. Conclusions: The mounting number of drug shortages has created a health care crisis, requiring changes in management strategies as well as clinical practice. The expanded phased approach outlined here provides a consistent, systematic approach for the management of drug shortages.

  • Saturday morning coffee [February 9 2013]

    MUG_ArizonaIt’s hard to believe that it’s February already.

    So much happens each and every week that 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….

    Last weekend I was on the road attending my daughter’s Power League volleyball tournament in Sacramento.  My brother Robert filled in for me admirably. I didn’t ask him to take up the reins, but I certainly appreciate him filling in the gap. Thanks, bro. Dig the mug by the way.

    I went through Phoenix, AZ twice this week while traveling for work, which made me think of the coffee mug to the right. It was once of four sent to me by Jason DeVillains last year. Jason is better known to many as The Cynical Pharmacist. Jason and I met via Twitter(@TheCynicalRPH) and have been chitchatting via the web ever since. Perhaps the next time I touch down in Phoenix I can lay over for a day and Jason and I can grab a cup o’ joe together. Jason also blogs over at The Cynical Pharmacist. Check it out.
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  • Accuracy of preparation of i.v. medication syringes for anesthesiology [article]

    Here’s an interesting article from the January issue of AJHP that talks about the accuracy of medication syringes used in surgical procedures. Some of the findings are a bit unnerving: “18% of preparations deviated from the declared dose by ±20%, 8% deviated by ±50%, and 4% deviated by ±100%“. Humans, we’re just not all that good at things like this.

    Accuracy of preparation of i.v. medication syringes for anesthesiology
    Cyril Stucki, Anna-Maria Sautter, Adriana Wolff, Sandrine Fleury-Souverain and Pascal Bonnabry

    Abstract

    Purpose: The results of a study of the accuracy of i.v. medication preparation by anesthesiologists are presented.

    Methods: The accuracy of syringe preparation was assessed by analyzing the contents of 500 unused syringes collected after adult and pediatric surgery procedures. The collected syringes contained various i.v. medication formulations representative of different preparation techniques: atracurium 1, 2.5, and 5 μg/mL and fentanyl 10, 20, 25, and 50 μg/mL, which required serial dilution after withdrawal of the drugs from ampuls; thiopental 5, 25, and 50 mg/mL, prepared by diluting reconstituted powdered drug from vials; and lidocaine 10-mg/mL solution, which was withdrawn directly from the ampul into a syringe. Variances between actual and labeled drug concentrations were determined via a validated ultraviolet–visible light spectro-photometry method.

    Results: Overall, 29% of the evaluated syringes were found to contain drug concentrations outside the designated range of acceptability (±10% of the targeted concentration); 18% of preparations deviated from the declared dose by ±20%, 8% deviated by ±50%, and 4% deviated by ±100%. In one instance, the actual drug concentration was at variance with the labeled concentration by >100%. In 4% of cases ( n = 20), discrepancies exceeded 100%, suggesting not just imprecision but errors in the preparation process, such as incorrect dilution calculations and selection of the wrong medication vial by the syringe preparer.

    Conclusion: Analysis of different i.v. formulations of four medications prepared in syringes by anesthesiologists revealed a high rate of discrepancies between ordered and actual drug concentrations, suggesting a need for increased institutional efforts to prevent errors during the preparation process.

    Am J Health-Syst Pharm. 2013; 70:137–42

     

  • The impact of prescription time guarantees on patient safety

    I came across an interesting article at the ISMP website this morning. The article details the results of a community pharmacy survey looking at what impact policies and procedures related to guaranteed prescription fill times have on medication errors. The results are predictable and scary.

    “Eighty-three percent of pharmacists working at pharmacies with advertised time guarantees reported that the time guarantee was a contributing factor to dispensing errors; almost half of them (49%) felt this contributing factor was significant. In fact, 44% of pharmacists working in pharmacies with time guarantees reported a dispensing error they were personally involved in, which was directly attributed to rushing to fulfill the time guarantee.”

    That right there is reason enough to not allow time guarantees when it come to filling a scripts.

    Read the rest of the article, especially the table of pharmacists’ perspective on time guarantees. It’s worth a few minutes of your time.

    Afterthought: Why do pharmacists continue to work in this environment? Do they like the work most of the time, and only hate it some of the time? I used to know a few pharmacists that worked in the retail sector of pharmacy, but they’ve all moved on. A couple went to work for PBM’s and two abandoned the profession altogether: one left pharmacy to become an accountant – he’s much happier these days – and another one just quit. I don’t know what she’s up to these days, but the last time we spoke she was dabbling in interior design.

  • Cool Pharmacy Technology – Diana Hazardous Drug Compounding System

    I came across the Diana Hazardous Drug Compounding System from icumedical while doing a little internet surfing the other day. As the name implies it’s a small, closed-looped system designed for compounding hazardous medications, i.e. chemotherapy.

    The “Diana System” utilizes a dual channel system, one for small volume and another for larger volumes. It’s a little difficult to understand exactly what the device does without seeing it in action, which is what the video below is for. It’s a pretty cool concept. I like the fact that it’s compact and needleless, but there are a couple of things I’d like to see added to the device. It appears that there is a lot of manual programming with the “Diana System”. It would be nice if it was integrated with the pharmacy information system so that it could utilize barcode scanning to automate the programming, much like what we see on the newer generation of smart pumps that are hitting the market.

    From the website:

    Accurate, safe, and efficient hazardous drug compounding technology right at your fingertips.

    • User-controlled automated compounding for maximum accuracy & safety. Unlike automated technologies that require huge investments and do not fit within existing workflows, the Diana system cost-effectively keeps pharmacists and technicians in control of the compounding process from beginning to end.
    • Closed system assures safety of clinicians and the sterility of the mix.The Diana system fits under the hood of your biological safety cabinet and protects clinicians from exposure to hazardous drugs and accidental needlesticks while protecting the patient preparation from exposure to environmental contaminants.
    • Reduces risk of repetitive stress injuries. Free up pharmacists and technicians from many of the repetitive motions required during preparation and reconstitution and reduce the stresses and injuries that can occur as a result.
    • Increases efficiencies and reduces drug waste. By helping you improve the efficiency of high-volume compounding, the Diana system can deliver workflow efficiencies while helping you reduce drug waste by extracting every drop of drug from every container.

  • Upon further review – thoughts on ASHP Midyear 2012

    I’ve just returned from a week in Las Vegas, NV at ASHP Midyear 2012. The ASHP Midyear conference is the pinnacle of clinical meetings each year for most acute care pharmacists. For me it’s not that interesting anymore as I don’t attend as a pharmacist. It just more work days for me; long work days. I didn’t attend a single “session”, but did manage to find some time to walk through the exhibit hall once and catch up with some old friends.

    Enough of that, on with the thoughts:
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  • Combination lock to prevent blood transfusion errors? Why not

    medGadget: “Typenex Medical, a Chicago, Illinois company, has created a solution that pretty much eliminates the possibility for errors. The system utilizes a combination lock on the blood bag that will only open using a code printed on the patient’s armband. If a clinician accidentally attempts to open the bag using another patient’s code, it will stay closed and the transfusion will not happen.” – Simple, yet effective. Interesting concept, no?

    The product is called FinalCheck.