RxInformatics.com

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.

Bar code medication administration (BCMA) is nothing new, but remains a hot topic in healthcare nonetheless. Another topic that has generated significant interest in healthcare over the past couple of years is the use of smart pumps, which I have posted on before. Unfortunately for most hospitals the two remain independent of one another with no appreciable integration. The integration of smart pumps with BCMA was one topic of discussion at this years ASHP midyear. I attended a couple of presentations from healthcare systems that had successfully integrated information from their pharmacy information system (PhIS) directly into their smart pumps for use with their BCMA system. Like many other ideas presented at large conferences, the situation is the exception rather than the rule.

From Implementation Science 2009 Sep 25;4:62:

Abstract:

BACKGROUND: Health information technology and electronic medical records (EMRs) are potentially powerful systems-based interventions to facilitate diagnosis and treatment because they ensure the delivery of key new findings and other health related information to the practitioner. However, effective communication involves more than just information transfer; despite a state of the art EMR system, communication breakdowns can still occur. 123 In this project, we will adapt a model developed by the Systems Engineering Initiative for Patient Safety (SEIPS) to understand and improve the relationship between work systems and processes of care involved with electronic communication in EMRs. We plan to study three communication activities in the Veterans Health Administration's (VA) EMR: electronic communication of abnormal imaging and laboratory test results via automated notifications (i.e., alerts); electronic referral requests; and provider-to-pharmacy communication via computerized provider order entry (CPOE). AIM: Our specific aim is to propose a protocol to evaluate the systems and processes affecting outcomes of electronic communication in the computerized patient record system (related to diagnostic test results, electronic referral requests, and CPOE prescriptions) using a human factors engineering approach, and hence guide the development of interventions for work system redesign. DESIGN: This research will consist of multiple qualitative methods of task analysis to identify potential sources of error related to diagnostic test result alerts, electronic referral requests, and CPOE; this will be followed by a series of focus groups to identify barriers, facilitators, and suggestions for improving the electronic communication system. Transcripts from all task analyses and focus groups will be analyzed using methods adapted from grounded theory and content analysis.

Although the information in the article is only a design concept, it is still worth reading. Concepts like these could be useful for many outpatient as well as many inpatient alerts; labs that are outside normal parameters, results from blood tests, incorrect antibiotic choice following culture results, etc. With the advances in mobile technology, especially mobile communication devices, this is worth serious consideration

The ValiMed Medication Validation System by CDEX, Inc.

According to the ValiMed website:

CDEX’s technology stands alone, able to precisely identify medications in real time with its patented Enhanced Photoemission Spectroscopy technology.

Energy at a preset wavelength interrogates the selected substance, capturing a unique emission spectrum which is then compared to the propriety signature, resulting in a simple “VALIDATED” reading when matched.

Each medication reveals its own distinct and easily readable signature. By comparing the fingerprint of a tested medication against the signature for that medication in our data library, the ValiMed technology is able to verify a match, presuming there is one.

The ValiMed Medication and Narcotic Validation System offers superior value to hospital medication safety programs and quality control processes by:

- Providing immediate, real-time validation of the substance itself.

- Providing an opportunity to standardize and optimize internal medication safety processes including Training, QA and Regulatory Compliance.

- Providing a real-time means of validating narcotic returns and mitigating narcotic diversion.

- Providing pharmacy staff and clinicians with a simple, fast, straightforward and cost-effective way to ensure that the RIGHT drug in the RIGHT dose is administered to the patient.

Medication reconciliation is defined by JCAHO as “the process of comparing a patient's medication orders to all of the medications that the patient has been taking. This reconciliation is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions.” The process should be fairly straight forward, but it is actually very difficult and time consuming.

Most consumers don’t do a very good job of keeping track of their medications; much less the medication names, dosages, what they are used for and when they were last taken. It’s not uncommon on admission to the hospital for a patient to say things like “I take a blood pressure pill” or “a pain pill” or “a water pill”. As a pharmacist I can make gross generalizations about these medications, and can narrow the options down with aggressive questioning, but can rarely be sure without seeing the medication for myself.

Forni A, Chu HT. Technology Utilization to Prevent Medication Errors. Curr Drug Saf. 2009 Oct 7 [ePub]

This is a nice review article explores current technologies available to healthcare and what role they play in the reduction of medication errors. The article provides a short review of literature to support each technology reviewed. Technologies covered include: Computerized Physician Order Entry (CPOE), Clinical Decision Support Systems (CDSS), Patient Monitoring: Electronic Surveillance, Reminders, and Alerts, Telemedicine, Bar Code Medication Verification (BMV), a.k.a. Bar Code Medication Administration (BCMA), Smart Infusion Pumps, and electronic medication administration record (eMAR).

Actor Dennis Quaid gave the key note at the recent ASHP Midyear Clinical Meeting.   Initially I found it to be fantastic presentation.  Shortly after I felt cheated and conflicted.  Soon after the speech I ran into some folks that knew a lot of about the specific incident that brought Mr. Quaid to speak to the pharmacists organizations.  It turns out that he either took artistic license to embellish his presentation or out right lied about the details of the tragic medical error.   Either way, my respect for him was crushed.

His new born twins were victims of an awful medication error.  While the twins survived and are fine now, it was a horrible error.  This blog post does not mean to minimize the error.  As a father of twins, I was close to tears during the speech, and can not even imagine the emotional toll it must have had on him.

Mr. Quaid could have taken the large settlement from the hospital and rode into the sunset.  Instead he works to help bring attention to the issue of medication errors.  For that he is to be commended.   So why he would make up aspects of the incident is perplexing and disturbing.  I trust my sources of the details of the incident completely, therefore, believe them and not the details that Mr. Quaid recounted.  So here are some positive and negative specifics and selected commentary of the speech.

The complete speech can be downloaded here.
http://www.ashp.org/DocLibrary/MCM09/MCM2009-Dennis-Quaid.aspx

“You may have a nagging question – why is he here? He is not a pharmacist…he is an actor.”

There is a nice article in the November 2009 issue of Hospital Pharmacy on the use of clinical surveillance in pharmacy. I've mentioned these types of systems before here and here.

From the article:

Clinical surveillance tools are atype of clinical decision support system (CDSS), providing pharmacists with patient information that has been filtered according to predefined criteria and is presented at appropriate times to enhance patient care. These tools pull data from 3 sources—admission/discharge/transfer (ADT), laboratory, and pharmacy—and use clinical rules to analyze the data and alert the user of instances that meet the rules’criteria. Though there is some variability in methods across the different vendors’ products, these Webbased applications enerally function by interfacing (HL7) with the hospital’s information systems to securely pull the data to the vendor’s server where the data are analyzed against a set of clinical rules. Some vendors allow the client to build their own rules, some provide a foundational set of rules, and others do not allow user-defined rules. This is an important distinction to make when evaluating the different applications.

For more information try visiting John's Evernote repository for Clinical Decision Support.