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™.
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:
- Basic infusion rate
- Body surface area
- Conversion calculations
- Creatinine clearance
- And many more!
- Complex infusion rate
- Infusion rate tapering tables
- Dose preparation instructions
- Concentration checks
- 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™
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.
Check out this infographic representing RxWORKFLOW™:
(Click image to view larger)