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October 27, 2015

Pharmacists Find Ways to Make ADCs Work in the ED

Filed under: AJHP News,Clinical,Current Issue,Innovation — Tags: , , , — Kathy Biesecker @ 11:03 am

PHARMACISTS SAY AUTOMATED DISPENSING CABINETS (ADCs) can bring efficiencies to the care of patients in the emergency department (ED), but it’s important to ensure that nurses aren’t worried about being administratively locked out of the devices during a crisis.

PatriciaKienlePatricia C. Kienle, director of accreditation and medication safety for Cardinal Health Innovative Delivery Solutions, gave two examples of how such a crisis might come about: “A patient presents as a ‘John Doe,’ or it’s a trauma patient who you just have to take care of right away.”

At such times, she said, patient care trumps everything—including the usual procedures for logging the patient into the electronic medical record (EMR) system, routing medication orders to the pharmacy for verification, and releasing the drugs to nurses at the ADC.

“It happens in every hospital,” Kienle said. And, she said, hospitals devise different solutions to give ED nurses quick access to medications in such situations.

Michelle C. Corrado, system director of pharmacy services for Hallmark Health System Inc., of Medford, Massachusetts, said her organization’s ED nurses can use a “911 dummy” account in the Pyxis ADC when medications are needed for a patient whose information has not been entered into the EMR system.

“This was a way . . . for them to get access to the life-saving meds that they need without the patient’s name,” Corrado said. “It’s [for] somebody who’s unresponsive or unconscious or has no identification, and there’s no family there to help with the registration process, and they just need meds to get the patient out of the critical stage.”

William W. Churchill, chief of pharmacy services at Brigham and Women’s Hospital in Boston, said there’s no such dummy account to allow urgent access to the Omnicell ADCs in his institution’s ED. But nurses can manually create an entry in the devices for specific patients whose information isn’t available when a medication is urgently needed.

“They might type in ‘Smith, John, medical record number 123456789.’ And the Omnicell will accept that, and the nurse can get the drug,” Churchill said.

Corrado said any medication in the ADC can be removed by using the 911 dummy account. But she said the nursing staff is expected to use the patient’s correct account as soon as it’s available instead of continuing to remove medications using the 911 dummy code.

Both pharmacists said these solutions require pharmacy staff to be diligent about following up to make sure their dispensing records are accurate.

“Our informatics team gets a report of all the 911 entries that are made,” Corrado said. “So we can go back and get the information from the nurse in terms of who is ultimately attached to that so that we can get all the billing and everything correct.”

MichelleCorradoCorrado said the reconciliation process isn’t difficult, but it does involve manual data entry to correct the patients’ accounts.

A critical component of ADC use at Brigham and Women’s was the development of a list of medications subject to automatic pharmacy verification through the EMR system. Nurses can pull those medications from the ADCs, effectively overriding the pharmacy review.

“We have a defined list, which was done collaboratively between the ED, medical, nursing, and pharmacy. And we also collaborated and agreed upon which orders would be ‘autoverify’ and which would require a pharmacist’s review,” Churchill said.

He said an ADC in a trauma room will contain more autoverify medications than a dispensing device located elsewhere in of the ED.

“When a patient is in need, we need to be able to provide that drug,” Churchill said.

Overrides, like dummy accounts, must be reconciled, he said.

“We get a report that’s generated the next day. Then we ask the pharmacists that are staffing in the area to take a look at the overrides and make sure that they’re appropriate,” Churchill said.

Andrew Kaplan, pharmacy supervisor at St. Catherine of Siena Medical Center in Smithtown, New York, said his hospital installed ADCs in the ED nearly a decade ago after consulting with the ED staff about which medications to stock in the cabinets.

For situations when seconds count, as during “an absolute emergency,” Kaplan said, “we’ve created a dummy patient account called ’emergency patient’ to allow them to pull something out that’s urgently needed.”

We’re trying to leverage our electronic medical record and our automated dispensing cabinets to improve patient care.

In somewhat less urgent situations (e.g., a patient is not yet registered), nurses can type whatever information they have about the patient directly into the Pyxis unit and then obtain the medications, he explained.

“We encourage them to put in as much information as possible, so at least it gets entered as a temporary patient,” Kaplan said.

He said the hospital’s Epic EMR system is the brains behind the successful deployment of the Pyxis unit in the ED and the ability to reconcile dispensing records.

“Our Epic EMR knows everything that happens in Pyxis. So there’s a linkage between the two,” Kaplan said.

Kaplan said ADCs allow the pharmacy to store and manage “hundreds of units of medicines” in the ED and improve the drug delivery process in various ways.

“We’re trying to leverage our electronic medical record and our automated dispensing cabinets to improve patient care,” Kaplan said.

For example, he said, the Pyxis unit in the ED has “auxiliary towers” for the storage of i.v. antimicrobials and large-volume medication preparations. With this feature and changes to the EMR system, he said, nurses no longer “run back and forth from the emergency department to the pharmacy” to obtain i.v. aztreonam for patients with penicillin allergy. Now, he said, the drug is administered within an hour of ordering 64% of the time, compared with 16% of the time before the changes were made.

Linda Lipsky, director of pharmaceutical services at Methodist North Hospital in Memphis, Tennessee, since 1992, recalled that drug dispensing in the ED used to be “kind of a free-for-all,” with nurses essentially taking whatever they needed for their patients from medication carts.

When ADCs were first introduced, they didn’t really fix that problem, she said.

“There was no control over it at that point, because we didn’t have profiles,” Lipsky said, referring to the system through which the pharmacy views information in the EMR and reviews and verifies drug orders, allowing the release of medications from the ADCs. Without the profile process, she said, every medication in the ADC was essentially on override status.

Now, she said, her community hospital uses Omnicell ADCs with profiling enabled to ensure that a pharmacist reviews the orders before administration, with overrides allowed for emergencies.

Lipsky said pharmacy, nursing, and medical staff worked together to create the override list. Once the nurses became familiar with the profiling capabilities and the override drugs, the ADCs were better accepted, Lipsky said.

“Like any change that you make, it’s slow when you start because you’re not real familiar. But then once you get into it, it’s no big deal,” she said.

–By Kate Traynor, reprinted with permission from AJHP
(November 15, 2015; volume 72, pages 1921-1922)





October 16, 2015

Women in Pharmacy Leadership

Filed under: Clinical,Current Issue,From the CEO,Innovation,Managers — Tags: , , — jmilford @ 10:50 am
Paul W. Abramowitz, Pharm.D., Sc.D. (Hon.), FASHP

Paul W. Abramowitz, Pharm.D., Sc.D. (Hon.), FASHP

RECENTLY, I HAD THE PLEASURE of participating in an ASHP-convened Women in Pharmacy Leadership Steering Committee chaired by ASHP Past-President Sara White. The meeting was set  to discuss opportunities for ASHP to address the unique professional and leadership development needs of women in the pharmacy workforce.

The data shows that women represent the majority of pharmacists practicing today; however, they occupy far too few leadership positions in our profession and in healthcare at large, particularly at senior leadership levels.

The benefits of a diverse workforce are vast and include different perspectives and experiences that ultimately contribute to better decision-making and a more productive and robust workplace.

Other professions both inside and outside of healthcare face similar leadership disproportions. Women face a gender gap for leadership positions, with fewer women populating the upward leadership path, despite being the demographic majority. ASHP is committed to exploring how to minimize cultural factors and to create an environment for focused mentoring and leadership development of a new generation of women pharmacy leaders.

ASHP is committed to exploring how to create an environment for leadership development of a new generation of women pharmacy leaders.

As an ASHP member for nearly 40 years, I have always admired the organization’s readiness to lead in addressing some of the most complex changes facing our profession, healthcare, and society at large.

ASHP has always been ahead of the curve and has the tenacity to devote the time, resources, and attention necessary to find innovative solutions to continue to advance our growing workforce. The issue of women in pharmacy leadership is no exception as we seek to sponsor and promote women leaders.

The ASHP Women in Pharmacy Leadership Steering Committee will meet throughout the year and provide recommendations and advice to ASHP. The Steering Committee will proactively seek input from all ASHP members, and we are committed to taking the best ideas and implementing them into our programs in the interest of nurturing positive change.

I hope that everyone shares our excitement and enthusiasm about this important initiative. ASHP is looking forward to hearing your views. Thank you for everything that you do for ASHP, our profession, and our patients.



October 5, 2015

Children’s Pharmacists Design System that Cuts PN Errors to Nearly Zero

PN formulation is a complex, high-risk activity in which small errors can cause significant effects.

PN formulation is a complex, high-risk activity in which small errors can cause significant adverse effects.

PRIMARY CHILDREN’S HOSPITAL IN SALT LAKE CITY, Utah, has virtually eliminated parenteral nutrition (PN) errors.

This dramatic outcome is attributable to an automated electronic ordering and compounding system that allows prescribers to seamlessly enter PN criteria with the assurance that incorrect or potentially dangerous solutions will be rejected.

“The system covers prescribing, transcription, automated preparation, and labeling, and it gives prescribers everything they need right on the screen,” said Clinical Pharmacy Manager Mark W. Mackay, B.S.Pharm.

“By addressing those components, we reduced the error rate to nearly zero, leaving drug administration as the only remaining task where errors may occur.”

A Challenging Formulation

The Institute of Safe Medication Practices (ISMP) considers PN a high-alert medication because PN formulation is a complex, high-risk enterprise wherein small errors can cause clinically significant effects.

To meet the needs of practitioners, ASHP offers Guidelines for Providing Pediatric Pharmaceutical Services in Organized Health Care Systems as well as PN preparation books and resources. The National Advisory Group on Standards and Practice Guidelines for Parenteral Nutrition and the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) also offer clinical guidelines for PN.

Yet compliance with recommended safety practices is poor, and error rates remain alarmingly high. A.S.P.E.N. reports that precautions to prevent PN errors and harm are in place at only 58% of health systems.¹

Researchers have also identified serious gaps in safe practices, most prominently the lack of computerized pharmacy order entry (CPOE) and the need to manually transcribe orders to an automated compounding device.²  And according to the ISMP, error rates for complex solutions such as parenteral nutrition are as high as 37% for manual preparation and 22% for preparations that are partly automated.³

Jared Cash, Pharm.D., BCPS

Jared Cash, Pharm.D., BCPS

“For children, parenteral nutrition requires constant adjustments, because their needs change dramatically with age and size,” said Jared Cash, Pharm.D., BCPS, the hospital’s director of pharmacy. “From the prescribing step to formulation and administration, there are many opportunities for errors, be they misunderstandings about intended dosing, illegible handwriting, or calculation inaccuracies. The potential for injury is very high if it’s done incorrectly, and many pediatric patients have been harmed by PN.”

Solid data about PN errors is scarce, but in a four-year prospective study at a 471-bed academic teaching hospital, investigators found an error rate of 15.6 per 1,000 PN solutions.4  Errors were categorized as prescription (1%), transcription (39%), preparation (24%), or administration (35%).

Mackay saw a way to trim such unacceptably high numbers and tame the PN process from start to finish at his 350-bed facility. He assembled an interdisciplinary team composed of pharmacists, physicians, nurse practitioners, nurses, dieticians, biomedical informatics, and laboratory experts, who reviewed patient data and identified PN practices that introduced opportunities for medication errors.

The system tells me exactly what I need to do, and it knows what it can or cannot make.

Then, using software developed by the hospital’s IT department, the team fashioned a system that integrates CPOE with state-of-the-art automated drug compounding and calculates doses for each PN component based on a patient’s weight.

In January 2007, the hospital rolled out the system. For the next seven years, Mackay and his colleagues tracked its impact: Out of 84,503 PN prescriptions, only 230 errors occurred (equating to 2.7 out of 1,000 solutions).

Ninety-five percent of all errors occurred during administration, and there were no transcription errors. Twenty-one errors (9.1%) may have contributed to patient harm, but all of the events fell in the “temporary harm” category—none contributed to permanent harm. A cost analysis demonstrated average savings of $137,629 per year and a total sustainable savings of $963,403 over seven years, attributable to decreased waste elimination and direct formulary control.

Ensuring Safe Calculations, Streamlining Workflow

Users appreciate the system’s straightforward interface. A single screen with Windows prompts for CPOE also displays key information, such as recommended micro- and macronutrient levels, recommended caloric levels, and dose limits for various PN components.

Dan Jackson, M.D.

Daniel Jackson, M.D.

“Information such as the dextrose infusion rate, the percentage of lipids and proteins, and the composition of what I’m ordering is right in front of me as I fill in the spreadsheet,” said Daniel J. Jackson, M.D., a pediatric gastroenterologist and nutrition expert at the hospital. “The system tells me exactly what I need to do, and it knows what it can or cannot make.”

For example, one of the most formidable challenges in PN is ensuring that individual ingredients don’t precipitate out of solution—a potentially life-threatening hazard. Among the most common causes of precipitation is excessive calcium phosphate, noted Dr. Cash.

“The system calculates safe levels of calcium phosphate and eliminates the risk of precipitation. You don’t need another person to intervene and tell you that the amounts are incorrect,” he said. “If the amount of calcium entered breaches dose limits, the system will reject the order.”

He added that the system has also streamlined workflow at the hospital, where 40 to 50 PN orders are active on any given day.

“The system has definitely been a welcome change, and it’s allowed pharmacists to focus on the clinical work they were trained for rather than spending a lot of time doing tedious PN dose calculations,” Dr. Cash said.

According to Vicki Basalyga, Pharm.D., BCPS, director of ASHP’s Section of Clinical Specialists and Scientists, a number of factors contributed to the initiative’s success:

  • Right from the start, Mackay solicited input from a multidisciplinary team to ensure that potential errors would be caught.
  • The team opted for a completely electronic system for ordering and review, thereby eliminating the need for pharmacists to decipher prescriber handwriting or transcribe orders from patient charts.
  • The system tracks levels of non-nutritive additives, whose accumulation in patients receiving PN for extended periods may cause adverse events.
  • The system includes triggers to ensure that age-appropriate micronutrient supplements are addressed during order verification.

“At a minimum,” Basalyga said, “all of these components should be present in every parenteral nutrition program to deliver safe, appropriate, and cost-effective care to patients.”

–By Steve Frandzel


¹ Ayers P, Adams S, Boulatta J, et al. A.S.P.E.N. Parenteral Nutrition Safety Consensus Recommendations, J Parenter Enteral Nutr. 2014;38(3):296-333.

² Boullata JI, Guenter P, Mirtallo JM. A parenteral nutrition use survey with gap analysis, J Parenter Enteral Nutr. 2013 Mar;37(2):212-22;

³ Proceedings from the 2013 ISMP Sterile Preparation Compounding Safety Summit: Guidelines for Safe Preparation of Compounded Sterile Preparations.

4 Sacks GS, Rough S, Kudsk KA. Frequency and severity of harm of medication errors related to the parenteral nutrition process in a large university teaching hospital. Pharmacotherapy 2009;29(8):966-74.

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