The cleanroom environment, a.k.a. the IV room, is one of my favorite areas inside an acute care pharmacy. It is often alive with activity, and can often be the busiest area of the pharmacy. It is also a unique place since the use of intravenous (IV) medications is vital to the successful outcomes of patients, but at the same time can result in some of the most egregious errors in healthcare. While the IV compounding process is under tight control as demanded by USP guidelines, the method of preparation and distribution is decidedly more conventional, i.e. IV rooms often rely heavily on humans. It’s an interesting dichotomy found nowhere else in the pharmacy. It is for these reasons that I find it interesting that pharmacy IV rooms have lagged behind other areas of pharmacy operations in automation and technology.
However, that’s beginning to change. Pharmacy IV rooms are no longer overlooked when implementing innovative technologies. As pharmacy operations continue to evolve it is becoming clear that IV rooms are starting to receive their due respect.
A certain percentage of healthcare systems already utilize some form of technology in the IV room, however the numbers are small. A 2007 ASHP national survey on informatics found that, depending on number of beds, between 9% and 27% of facilities were utilizing some form of device in sterile product preparation1 (small-volume and large-volume parenterals). It is unknown what technologies these facilities were utilizing at the time of the survey.
Based on information from the 2011 Pharmacy Purchasing & Products survey on the State of Pharmacy Automation, adoption of automation and technology in the IV room remains low. Only 4% of those pharmacies surveyed were using a robotic IV device.2 Of those 4% most implementations were in large hospitals. Furthermore, the survey shows that the overall use of robotics in acute care pharmacies is declining. However, that same survey showed increased interest in IV room automation, specifically “workflow management” systems. Approximately 20% of all survey respondents indicated interest in implementing one of these systems, 10% within the next two years.
This was the focus of another recent Pharmacy Purchasing & Products article.3 The article discusses the implementation of IV workflow management tools at two sites within Indiana University Health: Riley Hospital for Children and Bloomington Hospital. According to the article “Prior to adopting IV management tools, [they] employed [a] rather unsophisticated method for processing IV orders common in many hospitals. Labels were printed for individual IV doses or batches three or four times a day and a pharmacist would hand off the labels at the cleanroom pass-through window for a technician to sort by time.” This is common practice in many acute care pharmacy operations.
Indiana University Health determined that their system was outdated and basically unsafe, which led them to search for a viable alternative. Their review resulted in the selection of an IV workflow management system because “such technology could provide the solution [they] needed to bridge the gap between [their] overall bar code scanning protocol and [their]IV dose preparation process.” Implementation provided Indiana University Health with several advantages over their previously utilized system for IV preparation. Items specifically mentioned in the article include:
Improved safety through the use of bar code scanning
Reduced waste
Expiration tracking for compounded medications
Standardized method of training and preparation
ncreased accountability
Improved data and reporting for medications compounded in the IV room
Overall the technology has been well received and successful at Indiana University Health. The article concludes with “this type of scanning should become the standard of care for all facilities with compounding processes in place.” I agree.
References:
Am J Health-Syst Pharm. 2008; 65:2244-64
State of Pharmacy Automation, Pharm Purch Prod. 2011
Pharm Purch Prod. Nov. 2011, Vol. 8, No. 11
Afterthought: DoseEdge is dominating the workflow management category inside the IV room at the moment. I've talked with a lot of pharmacy directors over the past 6 months and they're either using DoseEdge or evaluating it as an option. I wrote about DoseEdge nearly two years ago here.
Baxa Corporation webinar on "DoseEdge®: Changing Pharmacy Practice Through Workflow Management." Presented by Dennis Tribble, PharmD, FASHP. Original air date: March 25, 2010
It feels like a day doesn’t go by that I don’t receive an email letting me know of something cool for mobile devices. With the ever increasing onslaught of tablet and smartphone use in pharmacy practice it’s only a matter of time before everything will be available in some electronic media format.
In this case it’s ASHP’s Interactive Handbook on Injectable Drugs: IV Decision Support by Lawrence A. Trissel. Every pharmacist working in a hospital pharmacy knows about this reference. And if they don’t then they have a big problem because it’s only one of the most definitive reference sources for IV compatibility. Over the course of my career it’s simply been know as “the Trissel’s”. (kind of like “the Talyst”…just sayin’ – private joke people)
There’s a link in the ASHP web store leading to a “getting started video”, but I couldn’t get the video to run. Little bit of a fail. Perhaps ASHP’s never heard of YouTube. Who knows.
I received the email below a few days ago announcing that The Tarascon Pharmacopoeia is now available for Android and the iPad. I’m not a big fan myself, but the reference appears to be popular with certain crowds. Historically it’s more popular with community/retail pharmacists than hospital pharmacists. This might have something to do with the availability of drug pricing in the Tarascon Pharmacopoeia. Who knows.
80% were concerned with stolen personal information
64% were concerned with lost, damaged or corrupted files
62% were concerned with the misuse of information”
I’m not surprised by the numbers. In general people are afraid of change and the unknown. With that said, I think all you need to do is walk a patient through the paper processes that we use now to give them some insight into how bad things really are. Stolen and lost personal and medical information is a major problem within the current healthcare system. It’s not uncommon in any given week to hear about patient records that have been lost or stolen. And as far as misuse of information, well lets just say that’s all too common as well.
The advantages to an EHR outweigh the concerns listed above. Just sayin’.
I’ve been contemplating a new slate tablet PC. The market is full of them, which should make choosing one a piece of cake. Unfortunately it’s turning out to be much more difficult than originally thought.
The most common problem, for me at least, has been short battery life. Less than four hours just isn’t an option, which eliminates what I think is the best slate tablet on market the Eee Slate EP121. So you can imagine my elation when I saw the specs for the Fujitsu STYLISTIC Q550. The screen size of the Q550 is a little small, but the pen and multi-touch input along with the claims from the manufacturer of extended battery life, up to 8 hours, caught my attention.
I had the opportunity to play with the Q550 today, and I’m sorry to say that I wasn’t impressed. Writing with the stylus was painfully bad. I use my tablet computers to take notes and prefer using a stylus over my finger for navigation in many cases.
One of the first things I do when looking at a new tablet computer is rest my hand on the screen and start writing. You can see the results in the image below; pretty crappy. The screen kept registering my hand, making writing difficult. The writing became instantly better when I moved my hand off the scree; bottom right of screen.
The other problem with the tablet was the speed. It was downright clunky. According to the placard at the Microsoft Retail Store the Q550 runs an Intel Atom Z670 1.5GHz process. Well, I don’t know how good the processor is, but it runs like a dog in this tablet computer.
Overall I was disappointed with the Q550. It’s not even on my list of potential tablet PCs anymore.
Still waiting for the right tablet PC to come along to waste spend my money on.
ThomasNet News: “PharmASSIST OPTIx enables remote prescription verification by taking a high-resolution image of each prescription's vial contents and vial label, and automatically displaying them on a designated pharmacist's workstation. The pharmacist compares these images to the appropriate drug image from a standardized drug database, along with specific prescription details to complete the verification. The verifying pharmacist can be stationed anywhere - in the front of the pharmacy counseling patients or offsite at another pharmacy, a central processing center, or working from a home office. PharmASSIST OPTIx stores each prescription's images as part of the patient history record, enabling pharmacies to quickly retrieve them for pharmacy benefit manager (PBM) audits and to confirm the quantity dispensed.
Pharmacies can use PharmASSIST OPTIx in stand-alone mode or integrated with Innovation's PharmASSIST Symphony® workflow systems, which enables end-to-end prescription tracking, problem management, and reporting. In addition to processing a pharmacy's countable medications, PharmASSIST OPTIx handles all non-countable products (e.g., ointments/creams, liquids, syringes, inhalers, etc.) for prescription filling and remote verification. The system can also assist pharmacies with physical inventory control.”
It reminds me of a non-cleanroom version of DoseEdge.
Additional automation is needed for it to be a real game changer, but it’s still pretty cool technology. It would be slick if the person filling the prescription never had to touch the product and the end result could be remotely verified.
I don’t consider myself a technology geek, but I do consider myself a power user. I like technology, but I’m not typically the guy who goes rooting around in the assembly of an operating system.
Recently I’ve been thinking, out loud, about getting an Android tablet. I’ve also been bemoaning the fact that I’ve never rooted an Android device. I’ve thought about rooting my Droid, but haven’t done it. I’ve also toyed with the idea of purchasing a Barnes & Noble Nook Color just so I could root it.
Well, my awesome wife and kids heard my rumblings and bought me a Nook Color for Father’s Day for the sole purpose of rooting it. That’s pretty darn cool.
Here’s the poem my kids wrote me that was attached to the box. They made me read it before I could open the gift and asked me if I caught the hint. I did.
Dad,
Today is a day made just for you,
To honor and celebrate all that you do.
We love you with all of our hearts,
Even when you let loose a fart.
We hope that made you smile,
Because it took us quite a while.
You’ve given us strong roots to help us grow,
And now a gift we will bestow,
Upon this day, we love you so.
Now take this gift and root it well,
We hope you think it’s very swell.
We wish you luck on this task.
If you need help just ask,
Because you have two brilliant daughters,
Who will always look up to their one great father.
Now this is getting much to long,
So take this gift and be gone.
Love,
Mikaela and Josslyn
Rooting the Nook Color turned out to be much more difficult than I thought it would be. I had version 1.2 of the Nook software which is apparently designed to make rooting the device harder. Mission accomplished.
Fortunately there are a lot of really smart people in the world and they like tinkering with things a whole lot more than I do.
The first time I rooted the device I used this YouTube Video to get the job done. The kid in the video walked me through the rooting process step by step. It worked perfectly, but I was only able to layer Android Gingerbread on top of the Nook Color software. It was kind of cool, but I had a lot of trouble accessing the Android Market so I decided to jump in with both feet and burn the sucker to the ground and start over. Sounded great in theory, but it gave me some headaches and a little heartburn. I ended up turning my Nook Color into a doorstop for a few hours, but was finally able to get a complete Android Gingerbread v. 2.3.4 installed on my Nook Color, or should I say my new Android Tablet; dubbed FrankenNook by my brother, Robert.
Why did I chose Gingerbread over the other versions? Good question. I did quite a bit of research before starting the process at Gingerbread appeared to be one of the simpler installations as well as one of the most stable.
Thanks to the ladies and gentlemen at xdadevelopers for all their hard work and for putting the information up on the internet for all to enjoy. And thanks to my lovely wife and incredible girls for the gift.
Oh, the rooted Nook Color makes a great 7-inch Android Tablet. My wife asked me if I still wanted an “Android tablet” off the shelf, i.e. a Galaxy tablet or Xoom. The honest answer is no, not at this time. At the moment I’m enjoying the device immensely. When I get tired of it I’ll just re-flash it with Honeycomb. Just sayin’.
I’ve just spent four days at the ASHP Summer Meeting in Denver, CO. The meeting offered a nice variety of topics, but seemed to focus on medication safety and informatics more this year than in the past. In fact, this is the first year that ASHP has offered a medication safety tract at one of their meetings.
I avoided the more traditional sessions on therapeutics, choosing instead to focus on the informatics and medication safety sessions. Based on the information presented it was obvious to me that these two disciplines are intimately linked. After all, the idea behind much of the technology we use in healthcare today is to improve patient safety.
In 1999, the Institute of Medicine (IOM) published the now infamous To Err Is Human: Building a Safer Health System. The information presented in that report sent shockwaves through the healthcare industry. More than a decade later we haven’t seen much improvement in the number of mistakes made in hospitals, but To Err Is Human effectively changed the foundation of healthcare forever. While healthcare remains squarely focused on caring for patients, the approach to how we provide that care has changed dramatically. The interest on patient safety has generated an immense body of literature aimed at using automation and technology to improve patient care.
Before diving too deep, it’s important to understand where the errors within the healthcare system occur. Leape’s landmark paper in 1995(1) analyzing ADEs in hospitalized patients found that adverse events occurred as follows: ordering 38%, transcription 12%, dispensing 11%, and administration 39%. Bates found similar results in a study also published in 1995 in the same issue of JAMA (2). Bates found that of ADEs that were considered preventable, 49% occurred during the ordering stage, 11% occurred during the transcription stage, 14% occurred during the dispensing stage and 26% occurred during the administration stage.
Since the publications by Leape and Bates much work has gone into making the medication use process safer. At the forefront of this work has been an advance in automation and technology. Among those technologies being explored include: 1) computerized provider order entry (CPOE) for ordering; 2) pharmacy information systems and clinical decision support for transcription; 3) automated carousels, barcoding and automated dispensing cabinets for dispensing; and 4) barcode medication administration (BCMA) and smart pumps for administration. This isn’t an all-inclusive list, but rather an example to demonstrate the extent to which healthcare has gone to improve patient safety through the use of automation and technology.
With that said, I find it interesting that one of the most error prone steps in the medication distribution phase is often overlooked. I’m speaking specifically about the process of returning/restocking medications in the pharmacy. I have observed the process many times and outside the use of robotics, the system is completely manual, open to selection bias, full of interruption and fraught with error.
Example return/restocking process:
A series of medication are returned to the pharmacy.
The medications are placed in a return bin regardless of medication type, dosage form, storage requirements, etc.
Tablets in the return bin are sorted for restocking.
Someone, most likely a pharmacy technician takes the sorted medications and places them back into pharmacy stock.
The medications are now ready for use.
Notice that step number three above is highlighted in red. This is the step in the process that is most open to error.
Let’s just say that during the sorting process the medications are not sorted properly and a hydrALAZINE tablet finds its way into a hydrOXYzine bin. I’ve seen this happen many, many times. The packaging and names are similar so the single hydrALAZINE tablet goes undetected in the wrong bin. So the next time hydrOXYzine is needed in bulk, i.e. for an ADC replenishment, the hydrALAZINE ends up in the pile of hydrOXYzine tablets. Since the tablets are loose, the pharmacist checking the bag full of hydrOXYzine fails to see the single hydrALAZINE tablet.
The hydrALAZINE is mistakenly sent to an ADC cabinet along with the hydrOXYzine where a nurse pulls the hydrALAZINE from the ADC thinking it is hydrOXYzine. Sometimes the nurse fails to recognize the error and the hydrALAZINE is administered to the patient in place of hydrOXYzine.
Hopefully the facility utilizes BCMA and the error is avoided. However, only about 35% of hospitals in the country were using BCMA as of 2010(3). However, if the facility is not utilizing technology like BCMA, the incorrect medication is administered to the patient where it could potentially cause harm.
Although the example above involves several failures during the medication use process, it all began with a breakdown during the restocking phase. I’ve seen this exact error many times during my career, as well as many others caused by sound-alike-look-alike medications.
It’s clear to me that the return/restocking phase of the medication distribution process is the weakest link, and is rarely acknowledged when thoughts of improving the process come to mind. So what’s the answer? Does the process need to be automated or is a better manual process the answer? I don’t know what the solution is, but I think it’s time we gave it some thought.
References
Leape L.L., D.W. Bates, D.J. Cullen, J.W. Cooper, H.J. Demonaco and T. Gallivan et al. 1995. “Systems Analysis of Adverse Drug Events.” ADE Prevention Study Group. JAMA 274: 35-43.
Bates D.W., D.J. Cullen, N. Laird, L.A. Petersen, S.D. Small and D. Servi et al. 1995. “Incidence of Adverse Drug Events and Potential Adverse Drug Events: Implications for Prevention. ADE Prevention Study Group.”JAMA 274: 29-34.
Pedersen C.A., Schneider P.J., Scheckelhoff D.J. 2011. “ASHP National Survey of Pharmacy Practice in Hospital Setting: Prescribing and Transcribing – 2010” Am J Health-Syst Pharm 68: 669-88.
amednews.com: “With an estimated 81% of physicians using smartphones (up from 72% in 2010), according to a survey of 2,041 physicians released May 4 by Manhattan Research, Albany Medical Center was not alone in feeling pressure from physicians to allow them mobile access. Hospitals and health information technology vendors are realizing that the way to sell physicians on health information technology is to make it mobile. Instead of hospitals and vendors telling physicians to adapt to their preferred ways of using technology, physicians are gaining the power to sway hospitals and vendors to their preferred way of using it.”
There are a couple of take home messages from this article. First, the increased use of mobile technology is finally forcing healthcare systems to make changes to their approach to technology. It’s something that’s been needed for a long time. Second, the article clearly demonstrates that our healthcare system remains physician centric. It isn’t until physicians cry foul that changes are made. I first asked for “mobile support” in a hospital setting nearly a decade ago, and continued to ask for it until I left the industry about six months ago. Unfortunately I’m a lowly pharmacist. Even at the last facility I worked in, which considered themselves quite technologically advanced, it wasn’t until physicians began demanding iPad support that we got it.
The more things change, the more they stay the same. Just sayin’.
I attended one final session at the Summer Meeting today before heading back to the hotel to pack up my stuff, have some lunch and head for the airport; which is where I’m sitting now.
The session was titled Mobile Devices and Social Media: Enabling Your Professional and Personal Lives, and was delivered by Bill Felkey and Brent Fox. It was great. I thought I was pretty technology savvy, but I quickly found out that I still have a lot to learn. As with many sessions at this year’s Summer Meeting, this one was recorded and should be available at http://ce.ashp.org shortly. Do yourself a favor and go watch the audio-synched presentation. You won’t regret it.
I’ve always wanted to hear Bill Felkey speak, but until today had never had the chance. I was reading articles on pharmacy automation and technology written by Felkey a decade ago. I dare say that he was my inspiration for ultimately entering the informatics field. He’s engaging, incredibly intelligent and simply a master of his craft. And then there’s Brent Fox. He’s one of the brightest young minds in pharmacy informatics, and a Felkey protégé to boot. Fox has a great understanding of pharmacy informatics and has an obvious passion for what he does.
That’s enough of that. On with some general observations.
The conference
Probably the best ASHP Summer Meeting I’ve been to. ASHP did a great job of promoting the conference and getting people to attend. Registration was simple, the conference center was great, the social events were a welcome edition, etc.
The addition of a medication safety tract complimented the amount of informatics presented at this conference. The two disciplines, i.e. informatics and medication safety go hand in hand. You really can’t practice one without the other.
The use of social media is much better this year than in previous years. Pharmacy as a whole has come a long way when it comes to social media, but we still have a long way to go. Involvement of professional organizations is necessary, and ASHP has made it clear they’re taking a leadership role.
The double screens in the informatics sessions was well done; one for the presentation and the other for the informatics Twitter Stream. I thought it was pretty funny when the Twitter stream didn’t move for long periods of time. I’ve seen video of medical conferences where the stream is moving so fast that it’s hard to read.
The lack of Wi-Fi in the conference rooms was a real bummer. I think ASHP should take a long hard look at this for future conferences. With today’s technology Wi-Fi should be available at all times at conferences.
I noticed that this conference had more informatics content than I can recall in recent memory. Is that a sign of where the profession is headed or simply a coincidence? Only time will tell, but one thing is for certain, the profession will need more advanced automation and technology as it marches toward a new practice model.
Some of the presentations were a bit long. I think the day of 50-60 minute presentations is over. Perhaps it’s time for pharmacy conferences to take a long, hard look at the TED model; short, sweet and informative.
To my chagrin bullet points are not dead. I’ve had it hammered into my brain over the past 18 months that bullet points are evil and presentations should be more organic. Unfortunately most of the world doesn’t buy into that philosophy. I’ve found in both my work and professional life that people love bullet points. They don’t want to hear what you have to say, they want to read what you have to say.
The ASHP Summer meeting was “paper light”, meaning that the presentations were available online instead of given out as paper handouts. Bravo to AHSP for taking this step. On the other hand I sat at the “recharging station” and watched attendee after attendee print off presentation after presentation. It was disturbing. Get with the program people. What do you do with all that paper once you leave the conference? File it? I used to do that – take presentations home and file them, only to go through my file cabinet every couple of years and throw them out without ever having looked at them.
The city
I found Denver to be a nice little town.
The convention center was great. It was easily accessible, big enough to handle everything that was going on and close to plenty of things to do.
The hotels were all within a short walk of the convention center.
The 16th Street outdoor mall area was very nice. I found a lot of things to do down there in the evening. I also found the Mellow Mushroom pizza joint. Dude, that was some seriously good pizza.
People in Denver ignore the Walk/Don’t Walk signs. Cross streets at your own risk.
The cab drivers really like the sidewalk.
The weather was good this time of year. Not too hot and definitely not too cold. I walked around in short sleeve shirts the entire time and was comfortable.
The views were spectacular. I was in a room of the 9th floor of my hotel. Outside my window was a picturesque view of show capped mountains and green trees. Quite nice really.
Summary
The ASHP Summer Meeting was great. I learned a lot and had the chance to catch up with a few people. I would have loved to see more of my colleagues at the meeting as it seems none of us have time for anything these days. Regardless, I recommend that everyone considers attending the Summer Meeting 2012 in Baltimore. As I mentioned previously, information is moving too fast to wait a full year between major conferences.
My thanks to ASHP and all the presenters. Until next year.
