Jerry Fahrni

Tag: Patient Safety

  • Saturday morning coffee [October 13 2012]

    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….

    The coffee mug to the right is from The Sixth Floor Museum at Dealey Plaza in Dallas, Tx. My family and I spent some time there during our summer vacation in Texas. One of the things I really wanted to do in Dallas was visit Dealey Plaza and the site where JFK was assassinated. Well, I finally got that chance as my family and I spent some time walking around the plaza area, visiting the location of the assassination and spending a little time at the book repository and museum. JFK is one of the few men in history that I would have liked to have met in person.

    Taken 2 was #1 at the box office last weekend. My wife and I saw it last Saturday. Not bad. If you decide to go see it make sure you don’t want a good story line or incredible acting range. Just enjoy the senseless violence and be entertained. Hotel Transylvania was #2 at the box office. I saw that last night with my wife and youngest daughter. Good, clean humor. Worth seeing especially if you have little ones.

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  • Outsourcing sterile product preparation and the importance of quality assurance

    I’m sure you’ve heard about the recent meningitis outbreak tied to a contaminated batch of preservative-free methylprednisolone acetate. The story has received significant attention as more that 100 people have been sickened and as many as eight have died as a result of receiving an injection of the contaminated steroid (this data is already out of date since I started composing this post yesterday).
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  • Cool Pharmacy Technology – RxAdmix

    In this issue of The Imaginary Journal of Pharmacy Automation and Technology (IJPAT) we take a look at RxAdmix, a system designed to provide barcode scan verification in the IV room. Now why didn’t I think of that? Great concept when you consider the dangers associated with compounding an intravenous medication incorrectly. Doxorubicin? Daunorubicin? Eh, what’s the difference.
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  • Tight glycemic control has no proven benefits for children in the cardiac ICU [article]

    It looks like we’re still beating this dead horse. I thought we put the tight glycemic control issue to bed a while back. Then again I’ve been out of the game for quite some time, so it’s quite possible that I’ve missed something. Actually, it’s likely I’ve missed something.

    Tight glycemic control was all the rage in intensive care units (ICUs) all over the country in the late 90’s early 2000’s. Tight control was supposed to reduce infection, promote healing, improve outcomes, etc. Then we found out that tight control really didn’t do that, but it did cause a lot of adverse effects, namely severe hypoglycemia. Makes sense when you thing about it. Giving patient aggressive insulin infusions to keep blood glucose less than 110 mg per deciliter is bound to lead you down the path to hypoglycemia. Just sayin’.

    Every once in a while a new study shows up looking at tight glycemic control in the ICU. The most recent is a study in children. The nuts and bolts of the study? Basically there was no indication that tight blood glucose control showed any benefit in pediatric patients undergoing heart surgery. The results are from the Safe Pediatric Euglycemia in Cardiac Surgery (SPECS) trial, which was conducted at Boston Children’s and at the University of Michigan C.S. Mott Children’s Hospital. The full article appears in the September 7 online edition of the New England Journal of Medicine. It’s free to read, so I would encourage you to get it while you can. The article should be available in the September 27 print edition as well.

    SPECS examined tight glycemic control with insulin compared to standard glucose management in 980 children hospitalized in the cardiac intensive care unit (CICU). Results from the research showed that maintaining “normal” blood glucose levels [80 to 100 mg per deciliter] with insulin had no demonstrable impact on the incidence of care-related infections (such as surgical site infections and pneumonia), length of stay in the CICU, organ failure or mortality. And as expected, the glycemic-control group had a higher rate of severe hypoglycemia (<40 mg per deciliter) than did the standard-care group; 3% versus 1%, respectively. The rate of total hypoglycemia (<60 mg per deciliter) followed a similar pattern; 19% for the glycemic-control group versus 9% for the standard-care group.  Not surprising.

    Hey, it wasn’t all for nothing. The primary author of the article, Dr. Michael Agus had this to say, “There were two successes for this trial. One was that we were able to show that children and adults are different when it comes to the benefit of glucose control in an CICU. We were also able to demonstrate that we can safely control glucose in a young, vulnerable, sick population.” And there you have it, children are not adults and we can safely treat children under our care. Who knew.

     


  • Color to differentiate information on pharmacy labels

    I put this up the other day at my Talyst blog. I don’t often cross post between that blog and this one because I tend to keep the “corporate” blog a bit more watered down. But in this case I thought it was worth it. I’ve been thinking a lot about the use of color in pharmacy labels. I’m not sure why we don’t see more of it in pharmacy. It may have something to do with the limited number of suitable color printers and label stock. As prevalent as color printing is in the consumer world, you’d think it would be simple. Unfortunately it’s not.

    I for one think color has a place in the pharmacy. It could be used to improve patient safety, and when used appropriately improve workflow and operations.
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  • Forcing re-entry of patient ID cuts wrong-patient errors

    You know how websites make you double enter your email address and password when you sign up for a service? Well, apparently that’s not a bad system for making sure you have the right patient during order entry. You’d think we would have figured that out a while back, but then again this is healthcare we’re talking about; equation for healthcare technology “innovation” is ([today’s technology] -10 years).

    The study found that requiring clinicians to re-enter patient IDs resulted in a 41% reduction in wrong-patient orders. Single-click confirmation of patient ID reduced wrong-patient orders by 16%. It’s not all peaches and cream though. The study found that double entry increased order entry by 6.6 seconds. Oh no!

    Understanding and preventing wrong-patient electronic orders: a randomized controlled trial (J Am Med Inform Assoc. 2012 Jun 29 )
    Abstract
    Objective: To evaluate systems for estimating and preventing wrong-patient electronic orders in computerized physician order entry systems with a two-phase study. Materials and methodsIn phase 1, from May to August 2010, the effectiveness of a ‘retract-and-reorder’ measurement tool was assessed that identified orders placed on a patient, promptly retracted, and then reordered by the same provider on a different patient as a marker for wrong-patient electronic orders. This tool was then used to estimate the frequency of wrong-patient electronic orders in four hospitals in 2009. In phase 2, from December 2010 to June 2011, a three-armed randomized controlled trial was conducted to evaluate the efficacy of two distinct interventions aimed at preventing these errors by reverifying patient identification: an ‘ID-verify alert’, and an ‘ID-reentry function’.
    Results: The retract-and-reorder measurement tool effectively identified 170 of 223 events as wrong-patient electronic orders, resulting in a positive predictive value of 76.2% (95% CI 70.6% to 81.9%). Using this tool it was estimated that 5246 electronic orders were placed on wrong patients in 2009. In phase 2, 901 776 ordering sessions among 4028 providers were examined. Compared with control, the ID-verify alert reduced the odds of a retract-and-reorder event (OR 0.84, 95% CI 0.72 to 0.98), but the ID-reentry function reduced the odds by a larger magnitude (OR 0.60, 95% CI 0.50 to 0.71).
    Discussion and conclusion: Wrong-patient electronic orders occur frequently with computerized provider order entry systems, and electronic interventions can reduce the risk of these errors occurring.

  • Prenteral nutrition error [from #ISMP]

    From the latest ISMP Medication Safety Alert!, a mix up between an adult parenteral nutrition (PN) template in an electronic health record (#EHR) and one for pediatrics.

    The big difference between these two is how you order electrolytes; it’s a really big difference.

    The most shocking part of all this was that the error made it’s way through the physician that ordered it, a pharmacist that “entered the PN order” (I’m assuming in the compounding application), the “trained technician” that prepared it – missing the fact that the bag contained a whooping 2600mL of sterile water, the pharmacist that checked it, and finally the nurse that hung it. Swiss cheese anyone?
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  • Warning labels on outpatient prescription vials not so great after all

    Everyone has seen them, I know you have. Those little colored labels that the pharmacy slaps on your bottle when you get a prescription: “May cause drowsiness”, “Avoid excess sun”, “Do not take aspirin products without doctor approval” and so on. There are a ton of them. I remember seeing them lined up in front of me when I was working retail. Sometimes it became a game to see how many you could fit on the bottle without covering up valuable information for the patient. I’ve also been in pharmacies where the warning labels were simply printed alongside the medication label.

    Well, it appears that this tradition may not be the best way to warn patients about potential issues with their medication. I mean, who really reads those things anyway?

    A small study recently published in the journal PLoS ONE took a look at these warning labels and determined that people really don’t pay attention. Not surprising.
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  • Bar-code-assisted medication administration in the ED

    In reference to the following article:

    Including emergency departments in hospitals’ bar-code-assisted medication administration. Am J Health-Syst Pharm. 2012; 69:1018-1019 (don’t bother trying to access the article unless you have a subscription -#fail)

    EDs are terrible places for medication administration because the healthcare providers are always in a hurry secondary to the nature of this particular patient care area, i.e. emergencies. All too often medications go unchecked during the medication use process. And to make matters worse, the ED is often times the last place to get BCMA in a planned rollout. It’s also the place where things like BCMA get the most pushback from physicians and nurses.

    According to the article “Emergency departments (EDs) are patient care areas that are prone to medication errors. For this reason, we recommend that EDs be considered in any roll-out of BCMA. Studies have shown that the medication administration error rate in EDs is approximately 7%, with 40% of medication errors reaching patients.4,5 The results of these studies suggest that BCMA could reduce ED medication errors, yet this technology is noticeably absent from the ED.” Pretty much what I just said.

    In order to benefit from BCMA you have to be willing to deploy it to all areas of the hospital, including the ED. I heard a similar message earlier this year at the unSUMMIT when one of the speakers said that most facilities are far from 100% BCMA compliant because of areas like radiology, infusion centers, EDs, etc.

    Makes one wonder how accurate things like the 2011 ASHP National Survey of Pharmacy Practice are. Food for thought.

  • Observational time-motion study comparing trational med administration to BCMA in an ICU [Article]

    The article below compares medication administration between paper-based medication administration (PBMA), i.e. the traditional method and bar-code medication administration (BCMA). Unfortunately, as is the case with much of the literature in journals these days, the information is quite old. The data for this observational study was collected in two short spans in 2008 and 2009. The numbers are small, but interesting nonetheless. The results pan out as expected. Items of particular interest were that the nurses in the BCMA groupd spent more time talking to their patients compared to the PBMA groupd, but at the same time spent a heck of a lot more time on drug prep. The first item makes sense, but I’m struggling to understand the drug prep numbers.

    The article can be found in the May 2012 issue of Hospital Pharmacy. It is is available for free with registration.
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