The pharmacy professional's guide to products and career opportunities

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Pharmacy

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Using newtechnology safely

Closeup on aclosed-loopmedication system

JCAHO on infection risks withmedication bins

Avoidingmedication errors

Using newtechnology safely

Closeup on aclosed-loopmedication system

JCAHO on infection risks withmedication bins

Avoidingmedication errors

2 When new technologytriggers medicationerrorsBy Matthew Grissinger, RPh, FASCP,

and Nancy J. Globus, PharmD

If not used correctly, technologiesdesigned to make dispensing andadministering medication safer canactually compound the risk of errors.Here’s how to avoid the pitfalls.

9 5 steps to keepingpathogens out ofmedication storage binsAdvice from JCAHO about potentialrisks and how to minimize them.

10 Inside a closed-loopmedication strategyBy Cynthia T. Williams, RN, MSN,

MBA, FACHE

Take a look at one hospital’s medica-tion safety initiative that encompassesdispensing, administering, prescribing,and transcribing.

13 Med errors to avoidLearn from these mistakes others havemade.

The pharmacy professional's guide to products and career opportunities

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TM

Spring 2006

EDITORIAL STAFF

EDITOR Jane Benner, MS (LIS)CLINICAL DIRECTOR Anne Woods, RN, CRNP, APRN,BC, MSNSENIOR CLINICAL EDITOR Denise D. Hayes, RN, CRNP, MSNCONTRIBUTING EDITORS Cheryl L. Mee, RN, BC; Katherine W. CareyCOPY EDITOR Alina NardoneDESIGN DIRECTOR Edward W. RosanioCOMPOSITION SYSTEMS SPECIALISTS Robert A. Nanni, Janice RodanDIRECTOR OF JOURNALS PRODUCTION Karyn CrislipPRODUCTION MANAGER Pat LankfordDIGITAL COMPOSITION SERVICES MANAGER Diane PalubaSENIOR DESKTOP ASSISTANT Joyce Rossi BiletzADVERTISING SALES STAFF

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EXECUTIVE STAFF

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Good teamwork helps keep patients safe

At the Institute for Safe Medication Practices (ISMP),we have a strong team of pharmacists and nurses work-ing together to prevent medication errors. We knowthat any health care professional could be involved in amedication error. On the other hand, every health careprofessional can have an impact on keeping patientssafe. This is especially true when pharmacists andnurses work together as members of the same team.

Most errors are the result of miscommunication or weaknesses inour systems, things we may not be able to see but that profoundly affectthe quality of health care we give our patients. When we work as a team,we learn what each team member’s role is. We gain new perspectivesabout inefficiencies and weaknesses in the medication-use system.

Teamwork also reduces blaming attitudes. That creates a learningenvironment, where we can acknowledge flaws and discuss safety prob-lems without fear of blame, where we can create and implement solu-tions, and where we can change the system.

If you don’t know the names of the nurses “up there”—and theydon’t know yours—learn who they are and introduce yourself to them.Make the contacts, establish the connections, create the team. Buildingyour own medication error prevention team will create a better workingenvironment and a safer place for your patients.

Michael Cohen, RPh, MS, ScD, PresidentNancy Tuohy, RN, MSN, Medication Safety Specialist

Institute for Safe Medication PracticesHuntingdon Valley, Pa.

Pharmacy Insider 2 Spring 2006

IN THE BEST CIRCUMSTANCES, drug therapy helps pa-tients; in the worst, it can harm them. Welcome to theworld of medication therapy.

The medication use process can be labor-intensive anderror-prone. Thanks to rapid advances in technology, it’sbecoming safer and more efficient—but only if new tech-nologies are applied correctly and consistently. In this arti-cle, you’ll learn how new technologies—automateddispensing cabinets (ADCs), computer prescriber orderentry (CPOE) systems, and barcode-enabled point-of-caresystems—can help health care practitioners provide betterpatient care.

Use of ADCs is upA recent survey by the American Society of Health-SystemPharmacists (ASHP) showed that 72% of hospitals useADCs in their drug distribution systems. Besides stream-lining drug distribution, these systems can track drugcharges and help reduce costs—but they can’t improvesafety unless system design and use are carefully plannedand properly implemented.

More than 170 medication errors involving the use ofADCs submitted to the U.S. Pharmacopeia/Institute forSafe Medication Practices (USP-ISMP) Medication ErrorReporting Program revealed several unsafe practices. Ad-hering to the guidelines below can help your facility reduceerrors. We’ll provide case studies to illustrate some impor-tant points.

Steps to ADC safety• Avoid storing high-alert medications in ADCs. Drugsconsidered high-alert are likely to cause serious injury or

death if given incorrectly. They include heparin, warfarin,morphine, and concentrated electrolyte solutions, such aspotassium chloride. Although these drugs aren’t necessar-ily implicated in more errors than less dangerous drugs,the consequences can be devastating when an error occurs.If high-alert medications are stored in an ADC, special pre-cautions need to be in place to prevent errors associatedwith them. (See Preventing errors with high-alert medica-tions.)• Require pharmacist review of every medication order.This screening helps ensure that the right drug is pre-scribed at the right dose via the appropriate administrationroute. Unless an ADC system is set up to require pharma-cist approval, medications can be dispensed without orderscreening and the safeguard of an independent double-check is lost. If your facility stores high-alert medicationsin ADCs, failure to review orders compounds the risk ofserious injury or death from these drugs. Case study: A nurse received an order to administer “1 gram calciumgluconate I.V.” to a patient. Each of the six calcium gluconate vialsstored in the ADC on the unit contained 980 mg in 10 ml, but thenurse misread the label and believed that each vial contained only98 mg. Thinking she needed 10 vials to administer the dose, she con-tacted a pharmacist at home because the pharmacy was closed.The pharmacist detected the error and prevented a tenfold over-dose. • Never place medications in an ADC without an inde-pendent double-check, and ask nurses to return unuseddoses to the pharmacy, not the ADC. An incorrectlystocked system doesn’t protect anyone. The process of re-stocking medications is primarily a pharmacy function,but studies have shown that pharmacies don’t consistently

When new technology triggers medication errors Technologies designed to make dispensing and administering medication safer can actually compound the risk of errors if not used correctly. Here’s how to avoid the pitfalls.By Matthew Grissinger, RPH , FASCP, and Nancy J. Globus, PHARMD

use independent double-checks. In one study by the ISMP,56% of respondents reported that a pharmacist alwayschecks medications to be restocked in an ADC; 15% re-ported that such checks never take place. Over half of therespondents (54%) never verify correct drug placement af-ter restocking.Case study: A patient had orders for both MS Contin (controlled-release morphine sulfate) 15 mg tablets and for immediate-releasemorphine sulfate 15 mg tablets. A pharmacy technician loading theADC in the patient care area inadvertently loaded the MS Contin inthe pocket for the morphine sulfate immediate release and vice ver-sa. The patient received several doses of each but didn’t suffer anyapparent adverse reactions. A nurse removing the medication for asubsequent dose discovered the problem.Case study: A pharmacy technician pulled what she thought werevials of furosemide 40 mg/4 ml from pharmacy stock and, without apharmacist check, placed the medication in an ADC. A nurse on theunit preparing to administer 240 mg of furosemide took six vials fromthe ADC and drew them into a syringe. As she was drawing fluidfrom the sixth vial, she noticed precipitation in the syringe. Checkingthe vials, she found that five contained furosemide 40 mg/4 ml andone contained phenylephrine 1% 5 ml. The medications were in similar-looking amber bottles of the same size. • Never place medications with similar names or packagesnext to each other in the same drawer or bin. Look-alikedrug names and packages are the root cause of more thanhalf the errors reported through the USP-ISMP Medica-tion Errors Reporting Program. “Confirmation bias” iscommonly involved: Someone reading a drug name on anorder or package is most likely to “see” what’s most famil-iar to him and unlikely to question the validity of what he’sreading. This can occur when the pharmacy restocks theADC or when a nurse removes medications.Case study: A physician ordered ephedrine, but a hurried nursepicked epinephrine from the ADC by mistake, drew it into a syringe,and handed it to the primary nurse, who administered the epineph-rine. The patient suffered a period of hypertension and chest painbut recovered.• Separate look-alike medication names from each otheron the drug selection screen. In many systems, the nursescrolls through a computer menu on the ADC and selects amedication from an alphabetic list on the screen. Look-alike drug names pose an error risk, especially when theyappear consecutively.Case study: One facility reported three mix-ups between diazepamand diltiazem withdrawn from ADCs in the ICUs. In one case, thepatient received diazepam at the ordered diltiazem dose. In another,a physician noted the amber color of the diazepam vial as the nursewas drawing up what she thought was diltiazem. In the third case,the nurse caught her own mistake. The facility investigated theseerrors and concluded that once the wrong drug was chosen and the

cabinet “confirmed” that it was correct, the nurse removed the drugfrom the drawer that opened and didn’t check the vial.• Reduce the need to “work around” an ineffective or inef-ficient system. In some cases, a facility chooses an ADCsystem without asking nurses for input. Then when thesystem poses problems, nurses may find various ways towork around it—a practice that increases error risk.

For example, a facility may establish overrides to letnurses get emergency medications quickly without apharmacist’s review. Unfortunately, allowing overridescancels out this important safeguard. Other workaroundsinclude using the Inventory function to get patient doseswithout approved orders and removing extra medicationsfor one patient or multiple medications for multiple pa-tients while the nurse has access to the cabinet. (For rec-ommendations on safely using an ADC system, see Tipsfor using an ADC.)

Computer prescribing decreases riskAmbiguous orders are a common source of medication er-rors. To eliminate the problem, some facilities have intro-duced a CPOE, an electronic system designed to acceptonly complete orders typed in a standard format and con-forming to strict criteria. Besides reducing error risk, thistechnology eliminates time wasted when nurses and phar-macists must call prescribers for clarification due to un-clear handwriting or nonstandard abbreviations. (SeeClearing up confusion.)

All CPOE systems use computer software; the system’scomplexity can depend on the facility’s needs. Typicalpackages can include a clinical data repository, order com-munication, nursing medication administration, and a

Spring 2006 3 Pharmacy Insider

Tips for using an ADC

If your facility uses an automated dispensing cabinet(ADC) system, keep these pointers in mind:• Store drugs that require pharmacy order entry andscreening in individual compartments. All other drugscan be stored together in one drawer. That way, nurseswon’t accidentally take a drug that requires screening.• Put pediatric and adult medications in separate cabi-nets.• Remind nurses to remove only one dose of anordered medication. If the dose isn’t used, they shouldsend it to the pharmacy, not return it to the ADC.• Put allergy reminders for specific drugs, such as anti-biotics, opioids, and nonsteroidal anti-inflammatorydrugs, on the ADC. Some systems will let pharmacyand nursing staffs create alerts to appear on the screenwhen someone tries to access the drug.

Pharmacy Insider 4 Spring 2006

rules engine. During order entry, certain prompts alert theprescriber to potential problems. In some cases, the pre-scriber can request information about a drug or ask whythe system is making a recommendation.

Most facilities can customize the CPOE system to bal-ance safety with ease of use. The software’s sophisticationand the facility’s needs determine how many of the follow-ing elements are included:—default values for drug doses, routes, and frequencies—help with calculations—warnings about drug allergies, interactions, overdose, orcontraindications based on the patient’s lab values, otherdiagnostic studies, age, and weight—reminders about corollary orders, such as the need forblood glucose levels before prescribing insulin—drug-specific information, such as actions and indica-tions —a need for electronic documentation if the prescriberwants to override the system’s default values—alerts about drug costs.

Although CPOE may seem like a panacea, you can’tassume it’s perfect. Computer glitches and software insta-bility pose risks. Incorrect data built into the software orthe customization can trigger inappropriate prompts anderroneous orders. And although the intent of most CPOEsystems is to accept only clear and complete orders, eventhis safeguard may not prevent a prescriber from enteringan order into the wrong patient record or ordering awrong medication.

Fewer than 5% of health care institutions currently useCPOE. Implementation is very expensive. A facility mustmake a strong commitment to the system and support pre-scribers while they learn how to use it. Any facility that’sconsidering CPOE should involve a multidisciplinary teamto carefully compare whether a commercial or a self-developed system will best suit its needs. The ideal way tolaunch a CPOE system is to use it in just one patient careunit so the facility can study the results and iron out wrin-kles before introducing it to other areas.

Bar codes come to the bedsideIn the supermarket, bar-code technology speeds checkoutand improves accuracy, documentation, and inventorycontrol. Bar-code technology is available for health careapplications too, but few hospitals are using it except forVeterans Affairs (VA) facilities.

Lack of labeling standards may be a key reason bar-code technology hasn’t caught on. Although the Food andDrug Administration requires bar codes on all medica-tions, not all facilities have the equipment needed to scanthem. However, within the next few years, hospitals may

find bar coding more appealing—and you may be involvedin adopting a system.

Benefits of bar-coding medicationdeliveryBar-code medication systems offer several levels of func-tion. The most basic systems help verify that the right pa-tient receives the right dose of the right drug by the rightroute at the right time.

Standards for bar-code medication systems don’t cur-rently exist, but generally each patient and each nurse wearidentification (ID) with a unique bar code. Each drugshould have a bar code that includes its National DrugCode number uniquely identifying the form and dosage,such as “10 mg capsule.” Lot number and expiration datemay also be included.

A nurse preparing to administer a medication usingbar-code technology scans his own ID, the patient’s wrist-band, and each package of medication to be administered.The system confirms the nurse’s dispensing authority andthe patient’s identity, matches the patient with his phar-macy medication profile, records in an online medicationadministration record (MAR) that the medication is being

Clearing up confusion

Some abbreviations are known to cause confusion thatcan lead to medication errors, such as the uncertainty ofthe abbreviation “D/C.” Does it mean “discharge” or“discontinue”? If this abbreviation is misinterpreted, apatient could abruptly stop receiving a drug he reallyneeds. To avoid problems like this, every health carefacility should develop a list of unacceptable abbrevia-tions.

The Joint Commission on Accreditation of HealthcareOrganizations (JCAHO) has chimed in with its own list ofabbreviations that shouldn’t be used when transcribingorders. For example, “S.C.” is no longer acceptable asan abbreviation for subcutaneous; the JCAHO now rec-ommends “subQ” or “Sub-Q.” Better yet, spell it out.Also, “cc” is a no-no; it can be mistaken for “U” (units) ifwritten unclearly. The JCAHO recommends “ml”instead. (See http://www.jointcommission.org/PatientSafety/DoNotUseList.)

The bottom line: Make sure you don’t use unaccept-able abbreviations.

If nurses have any questions about an order, theyshould ask the pharmacist to clarify it with the prescriberwho wrote the order. Checking and rechecking eachmedication order helps ensure the patient is receivingthe right drug at the right dose using the right adminis-tration route.

High-alert medications are drugs with a heightened risk of causing significant patient harm when they’re usedin error. Although mistakes may not be more common with these drugs, the consequences of an error withthese medications are clearly more devastating to patients. Use this list to determine which medications requirespecial safeguards to reduce the risk of errors. This may include strategies such as limiting access to these med-ications; using auxiliary labels and automated alerts; standardizing the ordering, preparation, and administra-tion of these products; and employing automated or independent double checks when necessary. (Note:Manual independent double checks aren’t always the best error reduction strategy and may not be practical forall of the medications on the list).

Classes, categories of medications

adrenergic agonists, I.V. (e.g., epinephrine)

adrenergic antagonists, I.V. (e.g., propranolol)

anesthetic agents, general, inhaled and I.V. (e.g., propofol)

antidiabetic agents, oral

cardioplegic solutions

chemotherapeutic agents, parenteral and oral

dextrose, hypertonic, 20% or greater

dialysis solutions, peritoneal and hemodialysis

epidural or intrathecal medications

glycoprotein IIb/IIIa inhibitors (e.g., eptifibatide)

inotropic medications, I.V. (e.g., digoxin, milrinone)

liposomal forms of drugs (e.g., liposomal amphotericin B)

moderate sedation agents, I.V. (e.g., midazolam)

moderate sedation agents, oral, for children (e.g., chloral hydrate)

narcotics/opioids, I.V. and oral(including liquid concentrates,

immediate- and sustained-release formulations)

neuromuscular blocking agents (e.g., succinylcholine)

radiocontrast agents, I.V.

thrombolytics/fibrinolytics, I.V. (e.g., tenecteplase)

Specific medications

amiodarone, I.V.

colchicine injection

heparin, low molecular weight, injection

heparin, unfractionated, injection

insulin, injection

lidocaine, I.V.

magnesium sulfate injection

methotrexate, oral, nononcologic use

nesiritide, I.V.

nitroprusside sodium for injection

potassium chloride (concentrate) for injection

potassium phosphates injection

sodium chloride injection, hypertonic (more than 0.9% concentration)

warfarin

Preventing errors with high-alert medications

Take special precautions with drugs identified as especially risky by theInstitute for Safe Medication Practices.

BackgroundBased on error reports submitted to the U.S. Pharmacopeia and Institute for Safe Medication Practices’ (ISMP) MedicationErrors Reporting Program and reports of harmful errors in the literature, ISMP has created a list of potentially high-alertmedications. During August and September 2003, more than 350 practitioners responded to an ISMP survey designed toidentify which of these medications were most frequently considered high alert by individuals and organizations. Further, toassure relevance and completeness, the clinical staff at ISMP, members of our advisory board, and safety experts through-out the United States were asked to review the potential list. This list of drugs and drug categories reflects the collectivethinking of all who provided input.Source: Institute for Safe Medication Practices, http://www.ismp.org.

Spring 2006 5 Pharmacy Insider

Pharmacy Insider 6 Spring 2006

prepared to give to the patient, and stores the information.For this reason, even the most basic bar-code system im-proves documentation.

A more complex bar-code system may include someor all of the following features:—inventory control with accurate drug counts —information from online medication reference libraries,including photographs of tablets and capsules, recom-mended dosages, contraindications, adverse reactions,warnings, pregnancy risk categories, and administration de-tails—customized comments or alerts, such as warnings aboutlook-alike/sound-alike drug names and key clinical actionsfor administering certain medications—a “rules engine” to check pharmacy and nursing ac-tions and to provide the staff with alerts or reminders.For example, it could check for cumulative dosing ofmedications with established maximum doses, such ascolchicine.—order reconciliation for pending or STAT orders (such asa prescriber’s order not yet verified by a pharmacist). Forexample, when a nurse enters a STAT order into the systembefore pharmacy receives it, the drug order is linked to theinformation of the pharmacy-entered order and helps pre-vent the patient from getting the medication twice.—the ability to capture data to monitor trends (such aslate doses and omissions). This analysis should not, how-ever, be used to assess employee performance and triggerpunitive action.—the ability to verify identification of lab specimens andadministration of blood products.

Unexpected problemsAs the pioneer in hospital bar coding, the VA system hasprovided a testing ground for the technology. A study ofthe VA’s bar-code use revealed five significant problemsclinicians need to consider when implementing a bar-codesystem.

1. Automated actions sometimes caught the nursesoff guard. For example, the VA’s bar-code system wouldremove medications from a patient’s drug profile 4 hoursafter the scheduled administration time, even if a medica-tion wasn’t administered. So, for example, if a patient un-derwent a procedure and returned to the unit more than

4 hours after the scheduled administration time, thenurses had no indication that an ordered medication hadbeen removed from the profile and that the patient hadn’treceived it.

2. Coordinating information between prescribers andnurses seemed more difficult. With a traditional paper-based system, prescribers could pick up the chart and re-view the handwritten MAR at the patient’s bedside or thenurses’ station. With bar coding, the prescriber must gainaccess to the nearest computer for this information, andsomeone else may be using it.

3. Deviating from the routine made more paperwork.The bar-code system documented a medication as givenwhen scanned. If a patient refused it after it was scanned,the nurses had to manually document the change—a time-consuming process. The VA had the system provider re-vamp the software so that nurses could easily document achange by selecting the medication and a menu option toindicate administration status.

4. Pressure to administer medications on time led to“workarounds” and new risks. Using the bar-code system,nurses had to type in an explanation whenever they gave amedication late, even if by only a few minutes. To avoidthe extra task, some nurses scanned and poured medica-tions when patients were unavailable so medication ad-ministration would appear timely in the record. As a result,unlabeled medication cups sat open and the nurses had toremember to administer the drugs when the patients re-turned, compounding the risk of errors.

5. “Time-saving” strategies defeated the system’s pur-pose. When scanning was ineffective (for example, becausethe curve of the patient’s wristband prevented the bar codefrom registering), typing seemed more efficient. So insteadof repeated attempts at scanning, some nurses routinelytyped in patients’ social security numbers rather than scan-ning the bar-coded wrist bands.

Safety firstBar-coding safeguards reflect well-established principles ofsafe drug administration, including proper identificationpractices, documentation, double-checking administrationof high-alert drugs, and avoiding preparation of medica-tions for multiple patients at one time. Although work-arounds are tempting ways to compensate for an ineffec-

Workarounds are tempting ways to compenstate for anineffective bar-code system, but they undermine

the system’s built-in safeguards.

Pharmacy Insider 8 Spring 2006

tive or inefficient bar-code system, they undermine thesystem’s built-in safeguards.

Organizations need to address some of the followingpotential shortcuts:—removing patients’ wristbands to scan them—scanning surrogate bar codes, such as those found on asheet of paper with multiple bar codes of commonly pre-scribed drugs—bypassing system checks designed to ensure that the cor-rect medication is administered.

To develop an effective, efficient system, any facilityplanning to institute bar coding needs to involve pharma-cists and nurses in decisions on purchasing, training for,implementing, and using the technology. With ongoinghelp from pharmacists and nurses, the facility can antici-pate potential problems, develop contingency plans, andperform stringent testing to assess for sources of break-downs, workarounds, or new types of medication errors.

Potential errorsBecause few organizations outside the VA system currentlyuse bar-code technology for medication administration,relatively few errors have been reported. A study of medication-use safety practices within America’s hospitalsand health systems found that only 4.4% of hospitals use amachine-readable coding to verify a patient’s identity andthe accuracy of drug administration before it’s given tohim. However, errors can certainly occur, especially in sys-tems with only very basic functions. Consider the follow-ing problems and scenarios.• Omissions. If the nurse scans the patient’s wristband andthe medication, then inadvertently drops the medicationon the floor, getting a new dose from the pharmacy willcreate a time lapse because the drug has been documentedas administered.• Extra dose. This could occur if the prescriber orders dif-ferent routes for the same drug and the system isn’t pro-grammed to raise an alert if both routes are selected. Forexample, if one nurse gives the patient an oral dose and iscalled away, another nurse could administer another doseby the I.V. route without a warning. • Wrong drug. This is especially possible when a medica-tion doesn’t have a bar code and the hospital must apply itsown.• Wrong dose documented. If the nurse has difficulty scan-ning and inadvertently scans a medication twice, the sys-tem may record a double dose even if the patient receivesonly one. • Unauthorized drug. The prescriber may order a medica-tion to be given only when a certain lab value, such as aninternational normalized ratio (INR), reaches a certain

level. If the system isn’t programmed to check the INR re-sults, it may fail to raise an alert and the patient may re-ceive the drug when he shouldn’t or fail to get it when heshould.• Documentation errors. Depending on how the prescriberwrites an order, the system may not be able to distinguishthe reason a medication is administered. For example, ifshe writes, Tylenol 650 mg P.O. four times a day as neededfor pain or temperature greater than 101º F, the documenta-tion may not indicate which indication the drug was ad-ministered to treat. • Wrong dosage form. Drug shortages may force the phar-macy to dispense a different strength or concentration(such as mg/ml) than what’s programmed in the bar-codesoftware.

Recognizing promises and pitfallsMany medication errors can go undetected during drugadministration, but the correct use of technology has beenshown to reduce errors or possibly prevent them. Now thatyou recognize the promises and pitfalls of ADCs, CPOEsystems, and bar coding, you can help your facility selectand implement these systems to protect patients and im-prove the way you deliver drug therapy. n

SELECTED REFERENCES

Barker KN, et al. Medication errors observed in 36 healthcare facil-ities. Archives of Internal Medicine. 162(16):1897-1903, September9, 2002.

Cohen, H, and Mandrack, MM. Application of the 80/20 rule insafeguarding the use of high-alert medications. Critical Care NurseClinics of North America. 14 (4):369-374, December 2002.

Institute for Safe Medication Practices. Survey of automated dis-pensing shows need for practice improvements and safer systemdesign. ISMP Medication Safety Alert!, June 16, 1999.

Johnson CL, et al. Using BCMA software to improve patient safetyin Veterans Administration Medical Centers. Journal of HealthcareInformation Management. 16(1):46-51, Winter 2002.

Patterson ES, et al. Improving patient safety by identifying sideeffects from introducing bar coding in medication administration.Journal of the American Medical Informatics Association. 9(5):540-553, September/October 2002.

Pedersen, CA, et al. ASHP National Survey of Pharmacy Practicein Hospital Settings: Dispensing and Administration. 2005.American Journal of Health-System Pharmacists. 63(4):327-45,February 15, 2006.

Making Health Care Safer: A Critical Analysis of Patient SafetyPractices. Agency for Healthcare Research and Quality Publication01-E058, July 20, 2001.

Metzger J, Turisco F. Computerized Physician Order Entry: A Lookat the Vendor Marketplace and Getting Started. Washington, D.C.,Academy Health, 2001.

Matthew Grissinger is a medication safety analyst at the Institute for SafeMedication Practices and Nancy J. Globus is a medication safety analyst forMed-E.R.R.S., both in Huntingdon Valley, Pa.

Report errors, close calls, or hazardous conditions to the ISMP at http://www.ismp.org orthe USP at http://www.usp.org. You can also contact the ISMP at 1-800-FAIL-SAFE or bye-mail to ismpinfo@ismp.org.

Spring 2006 9 Pharmacy Insider

ALTHOUGH MEDICATIONS THAT ARE protected inside sealedpackages are rarely contaminated, the bins storing thesemedications may harbor nosocomial pathogens. Thesepathogens can be a source of indirect contamination whensomeone touches the bin, carries the prepackaged medica-tion, and then touches a patient. Patients immunocom-promised by acquired immunodeficiency syndrome(AIDS), transplantation, or cancer therapy and patientswith increased susceptibility to infection as a result of dia-betes, trauma, or severe burns are at particular risk. Staffneeds to be aware of the possible infection control risksand take steps to minimize them. These five key strategiescan help:

1. Identify potential risks in your organization. Askpharmacy, nursing, and infection control staff for their ob-servations about how medication bins are used, whetherstaff uses gloves, whether the bins are carried into patientrooms, and under what circumstances the bins are cleanedor replaced. Organization staff may even want to take swabsamples to test for the presence of bacteria or molds.

2. Establish or review a cleaning procedure for med-ication bins. Many organizations clean a bin only when it’svisibly dirty or when they expect a regulatory or accredita-tion body to visit. But bins should be cleaned regularly,such as on patient discharge, regardless of their appear-ance.

Decide who’s responsible for cleaning (pharmacy ornursing) and when. For example, the cleaning procedurecould be added to the pharmacy’s regular cart-filling tasks.Include in the procedure cleaning automated dispensingsystems as well as nurses’ medication carts. Educate staffabout the importance of maintaining clean medicationbins to reduce infection risk. And, as always, emphasizehand hygiene and proper glove use.

If a bin is taken into an isolation room, it shouldn’t beused for another patient until it’s properly disinfected. Or-ganizations must use a disinfecting agent that’s broad

enough to kill the major organisms identified or those thatare potentially serious. Plain alcohol generally isn’t suffi-cient. Most disinfectants that are effective must be allowedto air dry for 10 minutes after application. Check with themanufacturer, especially with automated dispensing ma-chines, for suggestions on disinfecting products that won’tdamage the bin or machine over time.

3. Consider using bin liners. Although bin liners don’teliminate contamination, the risk is significantly reduced.Bin cleaning can be costly, time-consuming, and damagingto the bins over time. Disposable liners provide a consis-tent, convenient, and cost-effective method for maintain-ing clean bins. Bin liners can be replaced regularly andwhenever the liner becomes soiled.

4. Create a closed system for preparing intravenous(I.V.) medications. Preparing I.V. medications under alaminar flow hood keeps them in a relatively sterile envi-ronment. The laminar flow prevents objects from settlingon surfaces, so bacteria don’t settle on the I.V. bag or itscontents. After admixing the medications in the laminarflow hood, place a sterile cap (not a foil cap) on the I.V.bag while still under the hood. In this way, you create aclosed system that prevents bacteria and other infectionagents from getting into the I.V. bag. So even if the I.V. bagis placed in a nonsterile medication bin, the medicationwon’t become contaminated.

5. Monitor the state of medication bins for cleanli-ness. Infection control staff can add medication bin statusto their walk-rounds and ensure that the medication binsare cleaned properly. However, changing pharmacist andnurse behavior to consistently clean the bins will be thegreatest challenge. To prove medication bin cleanliness,consider documenting that medication bins have beencleaned, use the data in trend analysis, and benchmark thevalues. nSource: © Joint Commission Resources: Infection control in medical storage bins. PatientSafety Link. 2(1), January/February 2006. Reprinted with permission. Available at http://www.jcipatientsafety.org/show.asp?durki=11860. Last accessed April 17, 2006.

5 steps to keepingpathogens out of medication storage binsAdvice from JCAHO about potential risks and how to minimize them.

Pharmacy Insider 10 Spring 2006

IT’S BEEN 7 YEARS since the first of two Institute of Medicine(IOM) reports on medical errors put patient safety issuesfront and center before public and private policy makers.The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has issued National Patient SafetyGoals every year since 2002. When coupled with board-level directives, the pressure is on for hospitals to adopt anautomated medication management strategy to addresspatient safety.

The approach adopted by Alabama’s St. Vincent’sHospital addresses the IOM concerns and positions the fa-cility well for future regulatory requirements. Medicationmanagement is one of five clinical information technology(IT) projects currently underway at the facility, each partof an IT roadmap first developed in 1991. At its center is avast clinical data repository that close to 300 staff membersrely on daily.

Case in pointAt St. Vincent’s, providers can check every patient test, order, and procedure via an electronic results viewer, ac-cessible from wireless tablets and about 1,500 personalcomputers (PCs) deployed throughout patient rooms andnursing stations across the six-building hospital campus.In patient rooms, medical devices such as blood pressuremonitors are connected to each bedside PC, so vital signinformation doesn’t have to be reentered. Through dual-monitor computers at each nursing station, providers canreview digital radiographic images alongside current clini-cal data, such as medication orders, patient allergies, labo-ratory results, and other clinical observations.

Prescribers have secure “anytime, anywhere” Internetaccess to patient charts for electronic review and signaturefrom remote locations. Nurses also use a point-of-careclinical documentation system designed to map closely to

their workflow. It features an interface that adapts to eachnursing specialty, enabling faster charting. In addition, arules-based clinical alerts system monitors all clinical dataand proactively notifies caregivers of any situation thatneeds immediate attention or that could negatively affectpatient care.

Strategy launch, implementationNumbers vary by study, but generally show that 56% ofpotential medication errors occur during the orderingprocess, compared with 10% during dispensing and 34%during administration. Although the order and dispensingphases are critical to medication error prevention, 48% oferrors are intercepted there through normal processes andonly 2% are intercepted by the time the medicationreaches the administration phase. With these data in mind,St. Vincent’s staff chose to start with dispensing in thepharmacy, then move to administration on the floor, thentackle prescribing and transcribing.

Staff began by identifying the primary departmentalstakeholders (in this case, pharmacy and nursing) anddefining their objectives. The pharmacy wanted an auto-mated order entry system that would improve patientsafety; enable its staff members to be more clinically in-volved; and improve collaborations with nurses, pre-scribers, and laboratory staff. For nursing, the majorobjectives were to free up time for direct patient care andimprove documentation quality.

First, facility personnel implemented an advancedpharmacy information system with efficient electronic or-der entry and advanced clinical screening that checks fordrug/drug, drug/allergy, and therapeutic class duplications.They also deployed automated dispensing cabinets thatfeatured locked, sensed pockets to prevent clinician accessto nonprescribed medications, based on order information

Inside a closed-loop medication systemTake a look at one hospital’s medication safety initiative that encompasses dispensing, administering, prescribing, and transcribing.

By Cynthia T. Williams, RN, MSN, MBA, FACHE

received from the pharmacy system.When an order is completed in the new pharmacy sys-

tem, it passes electronically to the automated cabinets andto a bedside workstation that nurses must log into and useduring medication administration. A scanner attached tothe device captures a two-way bar-code match between thepatient’s wristband and the unit-dose medication packet.The integrated system confirms the “five rights” of medica-tion safety. If all elements are correct, the nurse adminis-ters the medication, which is charted in the medicationadministration record (MAR) and immediately integratedwith the patient’s other clinical documentation.

Change, not blameThe goal of any medication safety initiative is to preventerrors—not to assign blame. By upgrading the pharmacysystem and changing departmental workflow, clinicianscan better ensure that medications are administered duringthe right time frame, a common contributor to potentialmedication errors. In addition, pharmacists are more in-volved at the beginning of the medication process, estab-lishing starting times for medications in consultation withnursing. With better scheduling information, pharmacytechnicians now stock cabinets to ensure medications andsupplies are on the floors when and where needed. Thepharmacy also initiates and reviews the MAR, eliminatingduplication. As a result, nursing has an accurate MARthat’s always up-to-date.

Automation has also allowed St. Vincent’s staff to un-cover issues regarding drug dosage delivery to the floor andin some cases, has prompted changes to how medicationsare packaged. Clinicians have also been able to identify theneed for education on some new or higher-risk drugs.

Multitiered decision supportComputerized prescriber order entry (CPOE) virtuallyeliminates errors of commission (prescribing the wrongmedication or the wrong dose), omission (failing to pre-scribe a needed medication), and transcription (prescrip-tion misinterpretation). Experts in preventing medicationerrors, such as the Washington, D.C.-based LeapfrogGroup, favor systems that provide multitiered decisionsupport during the prescription process, incorporatingcoded medications and allergies, as well as standardized,formulary-compliant order sets.

This technology displays clinically relevant informa-tion about a patient’s condition, along with evidence-basedguidelines and treatment protocols. Moreover, these sys-tems proactively alert clinicians to time-sensitive informa-tion regarding critical patient laboratory and medicationvalues. For example, when a prescriber orders an amino-

glycoside through CPOE, the system checks the patient’screatinine lab values. If the value is normal, no alert is gen-erated. If the value is elevated, the system sends an alert tothe prescriber, advising of the lab value and the orderedmedication.

Prescriber resistance to CPOE can prove challengingdespite the system’s clear benefits. To win user acceptance,St. Vincent’s planners involved prescribers in every step ofthe process: vendor selection, content, workflow, and de-vices. A prescriber liaison/system analyst works one-on-one with clinicians to ensure efficiency of the workflowchange. And because the facility’s medical staff have al-ready experienced the benefits of previous IT initiatives,they’ve willingly participated in CPOE development andimplementation.

Where to beginWith this approach, St. Vincent’s is well on its way toachieving a closed-loop medication management system. Ifyou’re just formulating a patient safety or compliancestrategy, first consider upgrading pharmacy capabilities toan expert ordering system integrated with automated cabi-nets and deploying bar-code scanners at the bedside formedication administration. In St. Vincent’s case, thegreater capital outlay required for CPOE—despite itsvalue—strongly influenced the staff’s decision to begin inthe pharmacy and then move to medication administra-tion before undertaking CPOE.

You may also want to consider investing in anotherproven technology: a robot that responds to electronicmedication orders from the pharmacy system and auto-mates the stocking and dispensing of bar-coded unit-dosemedications. Whether you opt for a limited medicationmanagement strategy or a fully closed loop, the same criti-cal success factors apply. Your plan must reflect your orga-nization’s overall strategy and objectives. Project leadersmust involve departmental stakeholders early on. Finally, apervasive focus on improved patient safety and high-quality outcomes must drive each stage of the process,making health care truly safer—step by step. n

SELECTED WEB SITESInstitute for Healthcare Improvement. http://www.ihi.org.

Joint Commission on the Accreditation of Healthcare Organizations.http://www.jcaho.org.

The Leapfrog Group. http://www.leapfroggroup.org.

Last accessed April 17, 2006.

Cynthia T. Williams is vice-president of patient care services at St. Vincent’sHospital in Birmingham, Ala., a 338-bed facility that’s designated the FlagshipDigital Hospital for its health system.

Source: Updated from Inside a closed-loop medication strategy, ITSolutions, CT Williams,October 2004.

Spring 2006 11 Pharmacy Insider

TOPic for discussionIn yet another case of confusion over similar drug names, apatient was given Toprol-XL 100 mg instead of Topamax100 mg. She had a seizure disorder and had been takingTopamax for quite a while. A pharmacist who’d checkedthe order failed to see that the technician had retrieved thewrong drug, and Toprol-XL 100 mg had been dispensed inerror. The error was discovered a week later, when the pa-tient’s husband called the pharmacy and mentioned thathis wife had experienced a seizure. A pharmacist asked himto check the contents of the bottle labeled Topamax 100mg, and he discovered that Toprol-XL 100 mg had beendispensed in error.

Although standard pharmacy practice was to match thenational drug code (NDC) number on the stock bottle withthe NDC number on a computer-generated label and dis-pensing ticket, this important step had been overlooked.Similar product names might have caused the error: the“X” in XL for Toprol-XL looks like the ending of Topamax.These products might also be stored near one another ifmedications are stocked alphabetically by brand name.

In an earlier case, Topamax 25 mg had been dispensedinstead of Toprol-XL 25 mg. The person who reported thiscase related the mix-up to the imprint on the 25 mg Topa-max tablet, which lists “TOP” on one side and “25” on theother, facilitating the belief that the drug could be Toprol.(Other Topamax tablet strengths don’t share this charac-teristic.)

Don’t let this “flu” get youA physician assistant (PA) used a hospital’s computerizedprescriber order entry (CPOE) system to prescribe fluoxe-tine 100 mg P.O. b.i.d. for a newly admitted patient. Dur-ing the verification process, a pharmacist tried to call thePA to discuss the high dose, but he’d left for the day.

The nurse told the pharmacist that the patient was onthis dose at home and that an out-of-state psychiatrist hadprescribed it. The drug and dose were also listed on the pa-tient’s history and physical. The pharmacist asked the pa-tient’s wife to bring the medication from home. The drugwas then identified as fluvoxamine 100 mg, and the on-callphysician was contacted to clarify the order.

Errors like this—made when taking a patient’s homemedication history—are precisely the reason for the JointCommission’s National Patient Safety Goal requiring med-ication reconciliation at admission, transfer, and discharge.In this case, the pharmacist’s intervention prevented the

Med errorsto avoid

Spring 2006 13 Pharmacy Insider

Pharmacy Insider 14 Spring 2006

error from reaching the patient.This type of error still would occur in systems that

adopt the U.S. Pharmacopeia’s (USP) recent resolution forpractice settings—using only generic names for single-active ingredient products marketed after January 1, 2006.Using both brand and generic names provides a redun-dancy that can help prevent mix-ups between look-alikegeneric names.

Unfortunately, no brand product for fluvoxamine iscurrently on the market, and both fluoxetine and fluvox-amine are prescribed for obsessive-compulsive disorder.Using both “Prozac” and “fluoxetine” when prescribingthis drug and displaying its name on monitors, labels, andmedication administration records (MARs) would helpdecrease the risk of mix-ups with fluvoxamine. To be ableto display both brand and generic names, pharmacistsshould work with CPOE, pharmacy system, and electronicMAR vendors to ensure that drug names aren’t shortenedor abbreviated because of space restrictions on their prod-uct displays.

Chemical burnsAn ear, nose, and throat (ENT) resident physician workingin a hospital clinic was preparing to perform a myringo-tomy on a young woman. He poured about 1 ml of phenolsolution (89%, used to anesthetize the tympanic mem-brane) into a cup and put it on the counter in the treat-ment room.

The patient’s 3-year-old child was in the room, alongwith a relative who was supposed to be watching him. Un-fortunately, the child was able to grab the cup. Putting it tohis lips, he spilled the contents on his face and chest, sus-taining immediate pain and irritation to his lips, chin, chest,and abdomen. The involved areas were quickly flushed withwater and the child was transferred to a local children’s hos-pital. Examination revealed erythema and areas ofsloughed-off dead tissue (eschar) on the oral mucosa of hislower lip, chin, neck, anterior chest, and upper abdomen.The child also underwent a bronchoscopy and endoscopyto make sure his airway and esophagus weren’t harmed.

Before this incident, the hospital’s ENT clinic had beenreceiving bulk phenol from an outside pharmacy. Now thehospital pharmacy supplies the clinic and emergency de-partment with unit-dose phenol applicator kits (from Ap-dyne), reducing the potential for unintended exposure tothis harsh chemical. Additionally, children (unless beingtreated) no longer are allowed in treatment rooms. n

The reports described here were received through the USP-ISMP Medication ErrorsReporting Program in 2005 and are published here with permission from ISMP MedicationSafety Alerts! You can report errors, close calls, or hazardous conditions to the Institute forSafe Medication Practices (ISMP) at http://www.ismp.org or the U.S. Pharmacopeia (USP)at http://www.usp.org. You can also call the ISMP at 1-800-FAIL SAFE or send an e-mailmessage to ismpinfo@ismp.org.