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A forum for caregivers and pharmacy professionals concerned with patient and provider safety.

Eric Cropp

Technology, Technicians, Action!

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This post was updated on 06–18-20

The profession of pharmacy has certainly evolved in the years since my graduation and licensure. Significant improvements to patient care and an increase in quality outcomes are evident to any long-term observer of the profession. But this progress has revealed a major vulnerability. My goals are to bring this deficiency to light and to do something about it.

In addition to being the president and founder of RxTOOLKIT.com, I was formerly the operations manager of a large (700 bed) hospital. The pharmacy department there was fortunate to have the latest technology and a state of the art facility. They even provided a PGY 1 residency program and acted as a practice site for six different local schools of pharmacy.

As I interacted with students and residents, two things became apparent:

  • They are much better prepared for the clinical challenges of the profession than I was at that stage of my career
  • Most have little or no interest in operational jobs like mine (focused on dispensing and distribution)

Both observations make sense when you see the expanded role pharmacy is taking into so many different areas. In most hospitals now there are many different specialized areas in the pharmacy: clinical specialists, oncology specialists, and anticoagulant specialists.

Those clinical positions are the most sought after by recent graduates and the ones they are most prepared to do. But I wonder, “In the future, who is going to take care of dispensing and distribution?”

I ask that question often and the answer that I usually receive is, “These jobs will be done by technology and technicians.”

My reaction is two-fold, “You really don’t understand the limitations of the existing technologies” and “Where are we going to find these technicians?”

 

Technology

As I mentioned, the hospital where I formerly worked had the very latest in pharmacy technologies, including state of the art robotics. I am absolutely a strong proponent for technology and my company RxTOOLKIT offers many technologically based solutions.

Frequently, technologies are singular components in a larger workflow involving many moving parts.

As an example, let’s look at preparing a NICU stock solution and then repackaging the solution into individual syringes. Normally the following separate silos of technology are utilized:

  • Printer Application: Print the stock solution label capturing lot numbers / expiration dates
  • Barcode Verification Application: Barcode verify ingredients in preparation
  • Follow Established Procedure: Paper or electronic, centrally stored for reference
  • Printer Application: Print syringe labels for repackaging the stock solution dose into a syringe
  • Electronic or Paper Storage: Logging all of this in a book or online for regulatory compliance and quality control

Often times, these individual technology silos can be extremely expensive, severely limiting their practical use in smaller hospitals.

And I caution, that technology alone is not the answer. I have yet to see a technology that can be a substitute for understanding workflow and a well designed process. And even the best technology won’t work without well-trained people and an established process. Check out RxWORKFLOW™: Integrating Technology and Process or visit ivsafety.rxtoolkit.com for more on this topic.

RxTOOLKIT advocates for smarter solutions that incorporate technology with process and competency. We work hard to make the solutions we offer accessible and affordable.

 

Technicians

I drive a car. Before I could get behind the wheel, I had to prove my competency with both a written and observational exam.

I get my hair cut at a local barber. My barber has a framed license hanging on the wall proving her competency at cutting hair.

If I were admitted to a hospital in the United States, a pharmacy technician would almost certainly prepare any drugs given to me. Would there be a license I could point to that would demonstrate their competency? In almost every state in the country the answer is NO! Only 16 states currently require licensure as of this post, please see this post and the interactive map on the Emily Jerry Foundation’s site for more information.

Most hospitals do have an internal training program or may require technicians to pass a national certification exam. But there is no consistent, enforceable, governmental mandate. Who is responsible if something goes wrong? The pharmacist is the one who is accountable for what happens and is typically the only one with a license to loose.

How prepared are they for this responsibility? The answer: not particularly! Especially when education is moving further away from the skills required to supervise and perform operational tasks.

The extreme case of what can go wrong is former pharmacist Eric Cropp. The pharmacy technician’s error—missed by Eric—resulted in the death of two-year-old Emily Jerry. It also resulted in the loss of license, his career, and ultimately his freedom. Eric was the second victim in this medication error.

The pharmacy technician is a complex, sensitive, and extremely important job! We need to treat it as such.

 

Action!

We, at RxTOOLKIT, see the lack of standardization and training for pharmacy technicians as a significant patient safety issue and have made the decision to act.

We have become advocates for national pharmacy tech certification and are also lobbying for hospital pharmacy technician certification on a state-by-state level.

We have partnered with the Emily Jerry Foundation and Eric Cropp to help educate both the profession and the public about the changes that need to come.

RxTOOLKIT eLEARNING™ has also recently partnered with TRC Healthcare (Authors of Pharmacist’s Letter and Pharmacy Technician’s Letter) in advancement of Pharmacy Technicians University (PTU). This online competency‐based curriculum provides all of the tools and information needed to prepare techs for the job and the national certification exam.

Only after Emily Jerry’s tragic death, did the State of Ohio pass Emily’s Law requiring certification, background checks, and proven competency for pharmacy technicians. We don’t think it should take another senseless death to motivate change—We want Emily’s to be the last innocent life lost! If we can help prevent losing ONE MORE LIFE, isn’t it worth all of the ideas, energy, and passion we can muster?

 

Want to join the Zero Movement?

Please make a generous donation to the Emily Jerry Foundation.

Tell someone you know about Pharmacy Technician’s University, a portion of proceeds from the sale of these courses is donated directly to the Emily Jerry Foundation.

Contact us if you are interested in volunteer opportunities.

For more information about RxTOOLKIT eLEARNING™ please contact elearning@rxtoolkit.com or visit RxTOOLKITeLEARNING.com.

RxWORKFLOW™: Integrating Technology and Process

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This post was updated on 06–18-20

I am a Pharmacist, entrepreneur, and founder of several websites: RxTOOLKIT.com, RxTOOLKITLabels.com, and RxTOOLKITeLEARNING.com These sites, applications, and ultimately my life’s work, have principally focused on reducing preventable mediation errors. Our product 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. RxTOOLKIT® has created many innovative and essential tools and 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. Chris lost his little girl Emily, because of a medication error and has now 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 integrating them into a standardized PROCESS.

Following my conversation with Chris, I reflected on STAT events that occur often in clinical settings. My experience and reflection served to validate and strengthen our new approach. This breakthrough was wholly actualized in RxTOOLKIT’s latest development RxWORKFLOW™—User-friendly drug-specific monographs that provide reference, procedural information, and tools including RxQuickCALC™, RxCALC™, and RxDoseCHECK™.

 

Sully Sullenberger

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 crew members. 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.

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 for a clinician. 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 that day.

Anyone who has worked in a clinical setting has no doubt had some experience with STAT scenarios. In a hospital setting, they are often be initiated by an announcement coming in from the trauma department or the NICU. Medication orders can 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 medication preparation and delivery devices 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 got me through those times is the fact that I knew my job—inside and out. And my team, well they knew their jobs inside and out too. In a STAT situation, as I would begin to bark orders, clinicians would instinctively respond as they have been trained to do. In these times, it is the tools, training, and the established PROCESS that get us through. My staff worked as a cohesive team; each member assuming their role with knowledge and confidence.

As a pharmacy manager I had a responsibility to prepare my staff so well that it became instinct for them. Team leaders need to look at each task, identify the key process elements, and train, train and train. We must establish standardized processes as we break down complex procedures into manageable steps. We must provide the best technology and tools available. The entire team must be competent and fully understand how to use them.

And for me, above all else, it became clear that 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™: User-friendly drug specific monographs that provide interactive reference, procedural information, and tools including RxQuickCALC™, RxCALC™, and RxDoseCHECK™

RxWORKFLOW for IV Safety™ drug monographs provide the appropriate drug information, tools, and procedural information to support the safe preparation and administration of IV drugs. All information is professionally curated, continuously updated, and easy to find including:

  • Standard Infusion Concentrations
  • Dose Information
  • Use in Specific Populations
  • Warnings and Precautions
  • Drug Preparation Information
  • Drug Administration Information

Every RxWORKFLOW for IV Safety™ monograph includes on-the-spot tools that assist in preparation or administration. These tools are always what you need for that specific drug:

RxQuickCALC™:

  • Basic infusion rate
  • Body surface area
  • Conversion calculations
  • Creatinine clearance
  • And many more!

RxCALC™:

  • Complex infusion rate
  • Infusion rate tapering tables
  • Dose preparation instructions
  • Concentration checks

RxDoseCHECK™

  • Verify dose and infusion rate accuracy

Summary of Benefits:

  • Provides a single source of standardized reference, tools, and training
  • Enhances safety, consistency, and standard of care
  • Drug specific preparation and administration tools including RxQuickCALC™, RxCALC™, and RxDoseCHECK™

 

Conclusion

At RxTOOLKIT®, we believe that technology can unquestionably save lives and 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 preventable medication errors a reality.

Please contact us for more information about RxWORKFLOW™ or to schedule a live demo.

 

Check out this infographic representing RxWORKFLOW™:
(Click image to view larger)

Introducing RxWORKFLOW™ by RxTOOLKIT®

In Support of the Second Victim

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It has been 8 years since I made the biggest mistake of my life. I was responsible for the death of a 2‑year-old girl named Emily Jerry.

The emotional repercussions of this mistake still haunt me every single day—when I see the neighborhood kids playing, a commercial for the Children’s hospital, or a little blond blue eyed girl in line at the grocery with her mother. The tears well up in my eyes when I picture Emily, with all of her energy, riding her big wheel around the nurse’s station at the hospital where I worked. I can still picture her looking around with joy and discovery during the precious and altogether too short time that she graced this earth.

Personal / Professional Impact

I have been diagnosed with the medical emergency equivalent to post-traumatic stress disorder and have experienced a myriad of both psychological and physical symptoms.

The emotional impact of the error has affected both my professional and private life. I have experienced a full range of emotions: anger, fear, sadness, and shame. I have felt apprehension, panic, and disbelief. I have experienced loss of appetite and difficulty concentrating. I completely lost my self-confidence. I was terrified of being labeled as incompetent and careless by my peers, the general public, both Emily’s family and my own.

During the first few weeks following the incident, I felt isolated from my colleagues and the hospital—No one checked on me or offered support. I feared going to work. I experienced depression, guilt, humiliation, remorse, and frustration. I longed to reach out and try to make amends with Emily’s family.

The day I was dismissed from my employment at the hospital, I truthfully wanted to die. On the way home that day, I thought of turning the wheel into a bridge pylon and ending it all. I received a call from my mother at that very moment—it was the only thing that stopped me.

Even as time passed, all of these feelings stayed with me. I wasn’t equipped with the tools to process the intense and constant feelings. I suffered with insomnia, nightmares, flashbacks (even during the day), and continuing thoughts of suicide.

Every day seemed to drag on and on and I sunk into a deep depression. When I returned to work several months later, I felt so scared and incompetent that I could barely function.

Initially I didn’t think I would lose my license, let alone that the case would lead to criminal charges. I was wrong. In time, I lost my job, my license, and went to prison. I wondered how I would survive.

Healing

For years, I continued to suffer in silence.  In time I started to realize something needed to be done. As I began the process of personally healing from this terrible tragedy, I realized working towards prevention of these errors and helping others in the same or similar circumstances would become part of my own recovery. In my research as well as talking with others, I found an enormous lack of support for practitioners, who like me had become second victims in these unfortunate occurrences. Just as we take care of the patients and families affected by a medical error, we much also take care of the second victims.

Second Victim Awareness

In all of my personal and professional experience, I had never heard of a “second victim”. I was unaware that there were other health care providers that had gone through similar experiences. I eventually learned that following medical mistakes there is a documented increased risk for suicide. I learned about a nurse named Kimberly Hiatt, who took her own life following a medical error. It left me grieving that no one, including myself, had been there to support her.

I had an opportunity to meet Charles Denham, author of the article, The Five Rights of Second Victims, and Chairman of the Texas Medical Institute of Technology (TMIT). He maintains that second victims have five essential rights, represented by the acronym TRUST: Treatment that is fair and just, Respect, Understanding and Compassion, Supportive Care, Transparency and the Opportunity to Contribute.

When speaking with Charles, I learned not only that I was a second victim, but also that I wasn’t the only victim. He also believes that there is a third victim involved – the healthcare organization itself. The organization can include any professional involved in the patient’s care: from doctors and nurses all the way to the housekeeper or volunteer. The sustained “wound” that the organization feels can either be worsened or lessened based on the behavior of its leaders. Many professional leaders often feel conflicted loyalties to the patient, the healthcare system, and to their staff. In this way, they too, become victims of the error. When second victims are abandoned or ignored by their leaders, Charles believes the wound can infect the entire culture of the organization. When visiting my past employment, even after many years, you can still feel the hurt rippling throughout the organization. He suggests that by ensuring second victims are supported, the organization and its leaders can shoulder the outcome together and heal.

Industry Reaction

Not too long ago in pharmacy, we were encouraged to keep secrets about medication errors, trying in vain to maintain an image of perfection in the healthcare system.

As it stands, most of the medical profession tend to abandon, isolate, and punish the second victim. Both my research and personal experience has exposed a huge deficit in regards to the support of second victims. The healthcare profession cannot continue to blindly ignore this issue. They are currently failing to provide the fundamental and necessary resources.

Recommendations and Resources

The industry needs to provide accessible, effective, and long-term support that must be in place the before a traumatic event happens. Healthcare professionals and administrators need to promote widespread understanding of the second victim. Support initiatives need to be established and widely communicated. Education and discourse will help to lessen the stigma surrounding an error and increase the receptiveness of second victims to accept support.

In my opinion, one of the most important resources we can provide is a sense of community for second victims. By putting impacted caregivers in contact with others who have gone through similar situations, they realize that they are not alone. I now volunteer with the Institute for Safe Medication Practices (ISMP). I assist their second victim support programs and have also provided testimony for board hearings and criminal proceedings. I have seen first hand how many professionals, who initially felt isolated and defeated, can turn their lives around once they receive support.

I have started a support group in the Cleveland area for second victims. Through discussion, sharing of resources, and the establishment of a support system my hope is that we can create a safe and compassionate place for those in need. I have found a number of resources and organizations that were helpful in getting it started. Please visit our Resources page for more information.

Closing

Make no mistake; harmful events happen in all organizations, so leaders must be prepared. It is really not a question of if, but when. An emotional reaction to a medical mistake has the potential to lead leaders down a reactive and punitive pathway that can ripple negativity throughout the organization.

The industry must work to stop errors before they happen by increasing education and implementing technology and automation. Crisis management plans, that formally address the second victim, must be developed before they are needed. Health care workers must work to educate our peers and share these stories of caution—lessening the stigma surrounding a mistake and encouraging second victims to seek support. All facets of healthcare must work together, continuing to build the resources available for second victims, making them both accessible and highly visible within the system. All of us must remember to treat second victims as human beings who deserve respect and support.

My greatest hope is that by sharing my story and shining a bright light on this issue, it will serve as a catalyst for one the most important changes in healthcare—improved and long-term support of the second victim.

Feel free to leave a comment below, suggest additional resources, or contact me with any questions you may have. I can absolutely help to educate your staff and assist your organization in implementing a support system before a traumatic event happens. Contact me, I am available to speak to your group, either in person, or as part of an online program.

The Power of the Pen

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Power of the PenEver since my very first day on the job as a hospital pharmacist, I have placed a “C” using a blue Sharpie on every single label that I have ever checked.

While the “C” stands for Chuck, there’s no good explanation as to why this seemingly insignificant little marker chose me. I guess the first time I ever checked a prescription, I picked up a blue Sharpie.  Ever since that day, it is the only pen I would ever use.

Power of the Pen

Many of us who work in pharmacy have certainly considered the positive impact that we have on patients and fellow healthcare providers. In fact, most of us became pharmacists first and foremost because we wanted to help people.

I believe there are many of us that have not considered the tremendous power that the simple act of putting pen to paper can actually have.

I know that over the years my “C” has been placed on prescriptions that helped a patient recover from an illness or helped a NICU baby beat the odds. I know that my initial has done a lot of good.

I trust that my “C” has never done a patient harm. None of us in this profession would ever want to think of that possibility. The fact is that when you experience a “Near Miss”, as I have, it makes you look a lot closer, double check your work, and then check it again. It can also be pause to examine what is really important in your career and your life. For me, it became the driving force for the development of RxTOOLKIT and this blog. I want to ensure we do everything within our power to increase education and automation, as well as utilize the best technologies out there, so that we can ultimately save lives.

In the post I have written about my experience “My Near Miss”, we posted a survey asking, “Have you ever caught a “near miss” that could have caused patient harm?” 100% of respondents to our survey answered that they have had a near miss, 66.7% have actually had more than one! Click here to read the post and take the survey for yourself.

Obsession

Over time, I became rather obsessive and superstitious about the blue Sharpie. I would go to great lengths to be sure I always had the blue Sharpie with me. My secretary always keeps a box of extras hidden in a secret location known only to the two of us. The pharmacy techs I work with always keep extras around just in case I misplace my own. Even when the hospital wouldn’t order them for me, I began purchasing them out of my own pocket.

The Sharpie and the blue “C” became intertwined with my professional identity. Every script and label that crossed my path would receive the same exact treatment and became clearly identifiable as having crossed my path. Techs are always able to trace orders back to me. Once a pharmacy tech was double-checking a medication dose I had initialed. Something seemed wrong to him and he brought it back to me. Once verified, it was determined to be an incorrect dose—My Near Miss. Another time, I had checked a script of two Metroprolol 50mg and one 25mg tablet and initialed it as correct. Another pharmacist came to me to verify if it was accurate. In fact, it was meant to be three Metroprolol 25mg. Two close calls! Thankfully they were quickly identified and directly returned to me for verification before administration.

I even began receiving the markers as gifts! One of our pharmacy technicians once brought me a new “retractable” blue Sharpie. Another time, I received a miniature size blue Sharpie. Another pharmacist at my hospital even began to copy my behavior, but instead using a blue Sharpie to mark “J” for Jason.

Over time, the blue Sharpie unsuspectingly became an intrinsic part of who I am, a trusted partner, full of power and possibility.

Reflection

Until I recently began to reflect on my career and accomplishments, I hadn’t ever truly acknowledged the power of the pen. In fact in the 40 years I have spent as a pharmacist, I never thought much about my compulsive behavior until I heard Eric Cropp’s Story and had a chance to get to know him.

When I heard Eric’s Story for the first time, my immediate thought was, “My “C” on the wrong label, could do a patient harm (my worst fear) and also take away my career, my profession, and my life.”

I love this profession. Even at this time in my life, with the majority of my career years behind me, I still love what I do each and every day.  My heart will truly ache when the day comes that I have to put my blue Sharpie down for the last time.

Many of us who work in pharmacy, can clearly remember the errors and mistakes we have made. Some will be forever etched into our minds. It can be easy to let these events overshadow all of the successful actions we have taken, dispensing the correct dose, time after time.

This blue Sharpie and the power within, has taken on a deeper level of respect and importance to me. I am just as careful as I have always been, but I have now grown to consciously acknowledge the intrinsic power of the pen.

My Near Miss

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About 6 years ago I was working as the IV pharmacist on second shift and I was presented with a large number of IV’s to check prior to delivery.

The IV delivery to the nursing units was already late and I felt the pressure to get the IV’s checked as fast as possible. I was checking the lot of IV’s at a speed that I thought safe.

I checked one IV for D5W 1,000 mL with 50 mEq of Sodium Bicarbonate. As I checked it, I put my initial on the label and then moved on to the next IV. Something, and I don’t know what, caused me to stop and re-look at that IV one more time. I checked everything again and suddenly realized that the technician had injected 50 mL of Potassium Acetate 2 mEq / mL in the bag instead of 50 mL of Sodium Bicarbonate.

It is still difficult today to articulate how I felt at that moment. I was very close to physical illness. I don’t know what happened to make me look at that IV again, but I am so thankful that I did. I think about that incident whenever I think about Eric Cropp’s story.

I am fortunate to work in a hospital that has shown it lives by a just culture. I have witnessed personally how they have approached incidents and they do all they can for the patient, the family, and the caregiver.

Eric wasn’t so lucky. I know him and I know how difficult it is for him to live with the consequences of the error. I admire him so much for doing all he can to help the rest of us in our practice environments.

Please share your near miss with our readers. It helps to tell the story and it helps the healing process. It can also help the rest of us prevent it from happening to our patients. Report events through ISMP-MERPS to help protect your colleagues and their patients.

At the very least, please take our survey and stop back often to see what stories are being told.

We are all in the healthcare profession to help our neighbor.; certainly none of us wants to do any harm.

Hopefully by sharing our stories, we can help each other and bring awareness to prevention.