This post was updated on 3-11-15
I am an operations Pharmacist, entrepreneur, and founder of several websites: RxTOOLKIT.com, RxTOOLKITLabels.com, and RxHomeMed.org. These sites, applications, and ultimately my life’s work, have principally focused on reducing preventable mediation errors. Our development has always centered on technology, automation, and the advancement of tools. These tools assist in clinical decision making, minimize human errors, provide instant access to information, and improve the dosing and compounding of medications. Over the last 10 years my partner and I have created many innovative and essential tools. We have worked hard to make sure those tools were accessible, affordable, and easy to use.
Recently I had the privilege of spending time with Chris Jerry, President of the Emily Jerry Foundation. Eight years ago, Chris lost his little girl Emily, because of a medication error. Chris has dedicated his life to realizing zero preventable medication errors. At a point during my conversations with Chris, I had an epiphany regarding my life’s work:
I must enhance the methodology and development of tools for RxTOOLKIT®—in fact, improving how we approach the very process of development and implementation.
What became crystal clear to me, is that while tools and technology are tremendously important, what really makes the tools work is COMPETENCY and PROCESS.
Following my conversation with Chris, I reflected on STAT events that occur often in clinical pharmacy settings. My experience and reflection served to validate and strengthen our new approach. This breakthrough was wholly actualized in RxTOOLKIT’s latest development RxWORKFLOW™—a fully integrated and revolutionary new approach to pharmacy operations that is unlike any other product on the market today.
Chris mentioned that he had a chance to meet Sully Sullenberger, the pilot responsible for an emergency water landing of US Airways Flight 1549 in the Hudson River. Despite all of the notoriety he has received, Chris believed him to be a genuinely good and humble person. Chris said Sully is still confused over the attention he has received. Sully’s comment was, “I was just doing my job.”
It got me thinking about how well Sully must have known his job. He had very few seconds to make decisions that affected not only his own life, but also the lives of 150 passengers and 5 fellow crewmembers. In those few precious seconds, he made all of the correct decisions. The landing became known as the “Miracle on the Hudson”.
Was it a miracle? Or was it the result of a crew so well trained, so well prepared, that they instinctively knew what to do in the few seconds they had? I thought about all of the training and redundancy that makes up a pilot’s day. Pre-flight checklists so well memorized they could do them in their sleep. None-the-less, pilot and co-pilot go through the whole list together, before each and every flight.
In that intense and extremely stressful situation Sully MUST HAVE exercised solid leadership. Without a decisive leader, chaos would have easily ensued and lives could have been lost, even after the plane had landed.
Sully knew the process. He knew it so well that he instinctively performed it under extreme circumstances and with absolutely zero time to think.
STAT Events in the Pharmacy
Chaos can come at any time in the pharmacy. When looking closer at the Emily Jerry tragedy it’s easy to see that Eric Cropp, the pharmacist considered responsible for the error, was overwhelmed because of staffing issues, a computer system shutdown, and environmental distractions. One or all of these factors could have contributed directly to the error. All of the factors undoubtedly contributed to creating a STAT scenario for the pharmacy.
Anyone who has worked in a clinical pharmacy setting has no doubt had some experience with STAT scenarios. Usually they are initiated by an announcement coming in from the trauma department or even the NICU. Then the medication orders start coming in waves. It is easy to go from calm to chaos in just a few moments.
At the end of a rush, the team will usually spend some time reviewing each and every order, double checking packages to ensure that correct drugs were used, and analyzing reports from the BAXA pump to ensure there were no keystroke errors.
When considering the stress and chaos that can occur, I began to think about what really leads to a successful outcome.
Technology? Yes it helps.
But what really gets me through those times is the fact that I know my job—inside and out. And my team, well they know their jobs inside and out too. In a STAT situation, as I begin barking orders, both pharmacists and technicians instinctively respond and as they have been trained to do. It is the tools, training, and the established PROCESS that get us through. My staff works as a cohesive team; each member assuming their role with knowledge and confidence.
I have a responsibility to prepare my staff so well that it becomes instinct for them. Team leaders need to look at each task, identify the key process elements, and train, train and train. We must breakdown complex procedures into manageable steps. Implementing strategies such as a “Time-Out” at key points in the process serve to train, remind, and focus staff members. We must provide the best technology and tools available. The entire team must fully understand how to use them.
And for me, above all else, it became clear that competency and process must be fully integrated with the tools and technology that we bring to development. This new breakthrough can be clearly illustrated by looking at RxTOOLKIT’s latest development, RxWORKFLOW™.
Introducing RxWORKFLOW™: Integrating Technology, Process, and Competency
RxWORKFLOW™ is a fully integrated and revolutionary new approach to pharmacy operations. Our goal is to incorporate best practices from proven safety disciplines to provide our users with the safest approach possible. RxWORKFLOW™ combines the medication safety standards of ISMP, the regulatory guidelines of Joint Commission, and the process consistency of airline pilot training. RxWORKFLOW™ provides a distinct safety advantage and is unlike any product on the market today.
In developing this new approach, we focused on process and competency as much as technology. RxWORKFLOW™ walks your staff precisely through the steps to accomplish even the most complex procedures. RxWORKFLOW™ provides consistency, including standardized checklists, for both pharmacists and pharmacy technicians. We incorporated technology at critical junctures, providing tools for redundant tasks that can easily be casualties of distractions or confirmation bias. We include illustrations and images of drug packages to reinforce visual verification. Time-outs are included at crucial intervals to create focus and promote clear thinking.
As an added feature, RxWORKFLOW™ can be structured in a way that forces your staff to perform barcode verification scanning of ingredients using RxVALIDATE™. Unless they perform the required verification, the next step in the process will remain “locked” and they will be unable to proceed.
Let’s look at a break down of an RxWORKFLOW™ designed for drug specific compounding, labeling, and repackaging.
From a single primary source page in RxTOOLKIT’s Periodical Index, logged in users have instant access to the RxWORKFLOW™ including all the tools they need to get the job done, detailed step-by-step instructions of the process, and on the spot competency checks.
- We integrate time-outs throughout the process in order to create pause and build focus.
- We employ the use of a time-out bin. The bin holds the ALL of the ingredients and labels necessary to compound, label, and check the final product. We utilize a concept of “one bin – one compound” to minimize incorrect mixing of ingredients and/or labels.
- We incorporate on the spot competency tests using RxCOMPETENCY™—so you can confirm your staff is well prepared with the most current information.
- In looking at the potential pitfalls in compounding we focused on the need for barcode verification of ingredients (using RxVALIDATE™), review of the formula prior to preparation, as well as review prior to checking by the pharmacist.
- We looked closely at potential errors in labeling. The formula necessary for preparation is built right in to RxTOOLKIT’s Stock Solution Labels. By utilizing barcode technology, the information necessary for regulatory compliance (such as lot number tracking) is neatly contained inside a QR code on the label keeping the administration label free of distracting information.
- Transferring the correct information from the Stock Solution Label to the syringe or final product label is accomplished using RxPACK™. RxPACK™ utilizes barcode scanning instead of data entry avoiding potential keystroke errors.
- The steps are firmly established and consistent across all products:
1. Gather ingredients in specified Time-Out Bin
2. Generate Stock Solution Label from the Label Library
3. Barcode verification of ingredients using RxVALIDATE™
4. Compound directions
5. Checking of stock solution
6. Generate final product label using RxPACK™
7. Repackaging / Labeling using RxPACK™
8. Checking of Final Product
Each of these steps can ONLY be accessed on the primary source page for the drug specific RxWORKFLOW™.
At RxTOOLKIT®, we believe that technology can unquestionably save lives, that we need established training and strong leadership in the pharmacy. Independently, however, they are not enough. What will ultimately reduce preventable medication errors is the integration of process with intuitive technology inside the established workflow. I sincerely believe we can make Chris’s goal of ZERO a reality.
Check out this infographic representing RxWORKFLOW™:
(Click image to view larger)