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Preventable Medical Errors by the Numbers – Infographic by RxTOOLKIT®

March 20, 2015 by admin Leave a Comment

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Preventable Medication Errors by the Numbers – Infographic by RxTOOLKIT®

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References

All statistics regarding RxTOOLKIT are valid as of January 1, 2015. Please contact us if you would like more information.

1. http://journals.lww.com/journalpatientsafety/Fulltext/2013/09000/A_New,_Evidence_based_Estimate_of_Patient_Harms.2.aspx
2. http://www.ncbi.nlm.nih.gov/pubmed/23155743
3. http://www.pharmacytimes.com/publications/issue/2003/2003-09/2003-09-7372#sthash.I5QJECkL.dpuf
4. http://www.ncbi.nlm.nih.gov/pubmed/7791256 – L L Leape, D W Bates, D J Cullen, et al., “Systems Analysis of Adverse Drug Events”, Journal of the American Medical Association, 274 (1995), pp. 35–43
5. http://www.nap.edu/openbook.php?record_id=9728 – 1999 IOM report, Institute of Medicine (1999), To Err is Human: Building a Safer Health System,Washington, DC; National Academy Press
6. http://www.ajhp.org/content/54/8/904.short – E A Flynn, R E Pearson, and K N Barker, “Observational Study of Accuracy in Compounding IV Admixtures at Five Hospitals”, American Journal of Health-system Pharmacists, 54 (April 15, 1997), pp. 904–912.

Infographic Design and Illustration: DNC.media

If you would like more information or to schedule a live demo of please contact RxTOOLKIT.

 

Filed Under: Medication Safety, Pharmacy Technology Tagged With: awareness, medication error, medication safety, NICU, patient and provider safety, pharmacy technology, RxTOOLKIT, safety net

Insulin: One Patient – One Pen

September 2, 2013 by Chuck DiTrapano RPh Leave a Comment

“Health care has safety and quality problems because it relies on outmoded systems of work. Poor designs set the workforce up to fail, regardless of how hard they try. If we want safer, higher-quality care, we will need to have redesigned systems of care, including the use of information technology to support clinical and administrative processes”. 

This quote is from Crossing the Quality Chasm: A New Health System for the 21st Century, a consensus report from the Committee on Quality of Health Care in America published by the Institute of Medicine in 2001.

The curious thing to me is how when quality fails, it is often the individual practitioner who takes the fall and pays the price. What the Eric Cropp Story has told me is that the system failed him and failed him many times, but he and he alone owned the error. Eric’s tragic error occurred in 2006 and he was convicted and sent to jail in 2009,  8 years after Crossing the Quality Chasm was published in 2001. Apparently, the health care system has yet to embrace the changes recommended in 2001.

This post is about another potential system failure that could cause harm.

 

Chronology of Events

  1. November, 2006, The Institute for Safe Medication Practices (ISMP) published a Medication Safety Alert titled “PEN injectors: Technology is not without imPENding risks”. This first warned of impending problems with using this new type of technology.
  2. May, 2008, The Institute for Safe Medication Practices (ISMP) published a Medication Safety Alert titled “Considering Insulin Pens for Routine Hospital Use? Consider this….” This safety alert warned of potential hazards of using these pens, particularly the risk of cross contamination potential if the pens are not properly labeled.
  3. March, 2009, it was reported that 2,114 people may have been put at risk of AIDS and hepatitis by sharing insulin pens and cartridges in two Army hospitals in US.
  4. July, 2010, the FDA published a FDA Consumer Alert titled “Insulin Pens are Not for Sharing”.
  5. May, 2012, The Department of Health and Human Services (CMS) issues a Memorandum to all State Survey Agency Directors titled “Use of Insulin Pens in Health Care Facilities”. Among the discussion recommendations is “Insulin pens must be clearly labeled with patient/resident’s name or other identifiers to verify that the correct pen is used on the correct patient/resident.”
  6. February, 2013, ISMP publishes Medication Safety Alert titled “Hospital Should Reconsider Insulin Pen Use, Says ISMP”.
  7. In July, 2013, The American Society of Health System Pharmacists publishes an article titled “Biological contamination of insulin pens in a hospital setting”. The findings of that article were that of 125 insulin pens tested, 7 tested positive for cells or hemoglobin.

Plenty of evidence that a process change is in order and that a redesigned system of care, including the use of information technology should be developed to support clinical and administrative processes.

 

Magnitude of the Problem

According to the US Department of Health and Human Services, among hospital acquired infections, blood borne pathogen infections are a significant cause of morbidity and mortality. At any given time, about 1 in 20 inpatients has an infection related to hospital care.

From cdc.gov: “Applying two different Consumer Price Index (CPI) adjustments to account for the rate of inflation in hospital resource prices, the overall annual direct medical costs of HAI to U.S. hospitals ranges from $28.4 to $33.8 billion (after adjusting to 2007 dollars using the CPI for all urban consumers) and $35.7 billion to $45 billion (after adjusting to 2007 dollars using the CPI for inpatient hospital services). After adjusting for the range of effectiveness of possible infection control interventions, the benefits of prevention range from a low of $5.7 to $6.8 billion (20 percent of infections preventable, CPI for all urban consumers) to a high of $25.0 to $31.5 billion (70 percent of infections preventable, CPI for inpatient hospital services).”

Click here to download the CDC Clinical Reminder PDF.

 

Current System of Care Solutions Fall Short

Floor Stock Dispensing

Many institutions will have insulin pens available as a floor stock item in their Automated Dispensing Cabinets (ADC). The problem with this method of drug distribution is having a reliable procedure for the labeling of pens by the nurse at the time of retrieving the pen from the cabinet. I am aware of the label printing capability of the Omnicell system. To utilize this Omnicell capability, it appears that all of the cabinets must be upgraded to the newest Omnicell operating system and that the printing of the expiration date is limited to just one expiration date for all insulin pens. We understand that the room temperature expiration date is tied to a group of drugs and not to the individual drug. This results in the printing of the shortest expiration date (14 days) for all insulin pens, even an individual pen with a longer expiration date of 28 days must be printed with a 14 day expiration date, resulting in the potential waste of 50% of the drug.

Pharmacy Patient Dispensing

If the insulin pen is dispensed directly from the pharmacy, the pens must be labeled with Patient Name / MRN, room temperature expiration date and the time of dispensing. If this is done by the Pharmacy Operating System, one of the problems is finding space on the insulin pen to place the label without obstructing important information on the insulin pen label. Placing the label on the removable cap is a patient safety liability in that caps can be interchanged between patients.

 

Enhanced System of Care Solution

RxTOOLKIT Patient Specific Pen Label

RxTOOLKIT has developed a Patient Specific Insulin Pen Label designed to improve the safe administration of insulin pens if this manner of dispensing is chosen.

While we are not advocating the use of any one process or application, what we want to say is “Let’s do something to remove this patient safety exposure”.

This is an important ongoing patient safety issue and medsafetyonline.org is excited to hear from other health professionals. We invite you to please share your challenges and/or successes with all our visitors. Together we can pool our knowledge, improve the safety of our patients, and protect our health care colleagues.

 

Filed Under: Labeling, Medication Safety, Pharmacy Technology Tagged With: barcode scanning, look-a-like medication, medication error, patient and provider safety, reporting medication errors, safety net

Pharmacy Technician Certification – Christina Martin, PharmD, MS

August 23, 2013 by Chuck DiTrapano RPh 2 Comments

I began my pharmacy career in 2003 as a pharmacy technician for Weis Markets in Lancaster County, PA. My parents encouraged me to work in a pharmacy before I committed to six years of college.

What has always surprised me is the amount of previous experience and/or education required to be a pharmacy technician in Pennsylvania. In a modern period when states require hairdressers to be registered and tax accountants to be certified and licensed, it is amazing that pharmacy technicians can be hired without any credentials!

Eight states currently have no regulation of pharmacy technicians, which means that a sixteen-year-old without a high school diploma could be filling a patient’s prescription for injectable anticoagulants.

Ninety-six percent of all medications involve a pharmacy technician somewhere in the dispensing process.

The misconception is that all pharmacy technicians are certified; this thought is held by 73 percent of Americans.

As medication regimens become more complex and cost-conscious insurers rely on pharmacists to provide direct patient-care and medication therapy management, pharmacy technicians will continue to be called upon in-keeping pharmacy operations running smoothly. The number of pharmacy technician roles is anticipated to increase 31 percent by 2018 as a response to the redeployment of pharmacists and technicians need to fulfill distributive roles that do not require clinical judgment. The Pharmacy Technician Certification Board suggests that pharmacy technicians with formal education or training, previous work experience, and national certification will be specifically sought after to meet those demands.

My interest in pharmacy technician education and development was heightened during my pharmacy residency years at the University of Kansas Hospital. As a PGY1 resident, I had the opportunity to take a Health Policy course while working towards my Master’s degree in Pharmacy Practice Management.  We were tasked with identifying a “health care issue” and writing a proposal to address (fix) the issue.

I was aware of Emily Jerry’s story and wanted to create awareness of the need to train, register, and certify/license pharmacy technicians in all states. Registration allows the state to track and monitor who is designated as a pharmacy technician. Certification and licensure show that the technician has the pre-education through completion of an accredited pharmacy technician training program and passed an extensive competency exam. Requiring regulatory requirements will help ensure that a pharmacy technician has baseline knowledge of the job requirements.

In 2011, Pennsylvania proposed legislation that addressed not only the registration, certification and licensure standards, but also a minimum age and education requirement for technicians. Unfortunately, the proposed legislation died early in discussion.

In my lifetime, I hope to see resurgence in both the interest and importance of regulating pharmacy technicians. The uniform credentialing standards will promote health, safety and wellness in our patients!

What do you think?

Christina Martin, PharmD, MS

Filed Under: Medication Safety, Personal Stories, Pharmacy Law Tagged With: patient and provider safety, pharmacy technician, prevention, punitive action for medication errors, safety net

Practitioners on the Defensive

June 16, 2013 by Chuck DiTrapano RPh Leave a Comment

In the article titled: “Current approaches to punitive action for medication errors by boards of pharmacy”, the authors point out that most boards of pharmacy invoke punitive action against pharmacists involved in medication errors. Most states do not have specific rules or regulations that stipulate errors as actual violations and most determinations are made on a case-by-case basis.

Questions we are asking are:

  1. How many pharmacists are aware of this?
  2. How many pharmacists know the rules for their state?
  3. Do these rules apply to other healthcare professionals?
  4. What obligation does the hospital or other healthcare institution have in doing everything possible to create a safe work environment?
  5. If there is technology that would have prevented the error or minimized the potential for the error and it was not in place, does that responsibility then go to the hospital/institution?

A link to the article originally published on The National Center for Biotechnology Information site: Current approaches to punitive action for medication errors by boards of pharmacy.

Current approaches to punitive action for medication errors by boards of pharmacy. Holdsworth M, Wittstrom K, Yeitrakis T. Ann Pharmacother. 2013 Apr;47(4):475-81. doi: 10.1345/aph.1R668. Epub 2013 Apr 2. [Read more…] about Practitioners on the Defensive

Filed Under: Pharmacy Law Tagged With: medication error, patient and provider safety, pharmacy technology, punitive action for medication errors, safety net, working conditions

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