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July 22, 2013

Interprofessional Collaboration: ASHP’s Response to the AMA

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

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

In June of this year, the American Medical Association (AMA) passed a resolution that caused concern among many of us.  At first glance, it’s no wonder why the policy gave us pause, as it states that “a pharmacist who makes inappropriate queries on a physician’s rationale behind a prescription, diagnosis, or treatment plan is interfering with the practice of medicine.”

While this statement seems to throw up a barrier to the good, productive collaborative relationships that best benefit patients–and that pharmacists, physicians, and patients have all grown to appreciate–it’s important to look at what was at its root: this nation’s drug abuse problem.  The AMA’s statement is a response to the efforts of some pharmacies in light of the federal government’s stepped-up enforcement to prevent diversion and better control the epidemic of prescription drug abuse.

Certain pharmacies, in response to enhanced scrutiny and enforcement efforts by the Drug Enforcement Administration, are calling and faxing to verify the legitimacy of every controlled substance prescription before filling. The burden this has placed on some physicians’ offices gave rise to this new AMA policy.

I recently wrote a letter to the CEO of the AMA that stressed the long history of collaboration that exists between pharmacists and physicians in hospitals, health systems, and ambulatory clinics. My letter confirmed that ASHP would be pleased to work with the AMA and other stakeholders to find solutions to the broader problem of prescription drug abuse, which ideally would include more effective communications and interprofessional collaboration among pharmacists, physicians, other health care providers, policymakers, and law enforcement.

The nature of today’s health care delivery system depends on professional collaboration to make sure our patients are getting the best health care possible.  Over the course of my 35-plus years in practice, and here at ASHP, I’ve seen firsthand how that collaboration has grown exponentially,  and is now widespread, not only in our nation’s hospitals and clinics, but with our community pharmacy partners.

And, indeed, we hear the same from our physician colleagues. In fact, Richard Pieters, M.D., the physician who wrote the draft for the AMA resolution, described his working relationship with pharmacists as “excellent” in an interview with Pharmacy Practice News. He added that “pharmacists are very valuable members of the team.”

Pieters, who is a radiation oncologist at the University of Massachusetts Medical Center and president-elect of the Massachusetts Medical Society, went on to state that, as a physician who is board-certified in hospice and palliative medicine, he finds pharmacists to be “fantastic resources.”

With a strong commitment to getting to the right issues in the right ways, pharmacists and physicians can both be part of the solution to our nation’s epidemic of prescription drug abuse in a way that encourages the interprofessional collaboration that best serves our patients.

April 22, 2013

Boston Bombing Puts Hospital Pharmacies into Emergency Mode

Filed under: Current Issue,Feature Stories — Tags: , , , , , , — Kathy Biesecker @ 11:54 am

Ambulances line Columbus Avenue after two explosions went off near the finish line of the Boston Marathon April 15. Photo by David L. Ryan/Boston Globe via Getty Images

THE PEOPLE WHO ARRIVED in the emergency department on April 15, 2013, had injuries unlike any Nancy Balch had seen in her 12 years as an emergency department pharmacist at Massachusetts General Hospital in Boston. Their injuries were severe. At least one person had had a limb blown off.

“I’ve seen a lot, unfortunately,” she said of her decade-plus in emergency care at the level 1 trauma center, “but nothing like this.”

High Volume, Extensive Injuries

By the end of Balch’s regularly scheduled shift on Monday, the hospital had treated 29 people injured by the bombs that exploded near the finish line of the Boston Marathon.

People came to the emergency department the next day, too, Balch said. Some sought care because their hearing had not returned to normal. Others did not realize until Tuesday that they had a piece of metal stuck in them.

Shannon Manzi, at Boston Children’s Hospital, has spent almost as much time in an emergency department as Balch has.

“I have not seen these types of injuries since I was in Haiti,” said Manzi, who went there in 2010 immediately after the 7.0-magnitude earthquake.

But in Haiti, the patients had crush injuries, she said. On Monday, the patients at Boston Children’s had blast injuries. Both types of injuries can sever limbs.

The children hit by the blasts, however, had injuries more extensive than what Manzi had seen after the earthquake.

On Monday, Boston Children’s, a level 1 pediatric trauma center, received 10 patients from the blasts, the hospital has reported. Manzi said she had just torn down the medical tent at mile 15 in the marathon when her pager alerted her to a “mass casualty” at the hospital. The first two patients were in the emergency department when she arrived.

Good Decisions, Well-Made Plans

The bombs exploded about the same time as the overlap in day and evening shifts for emergency department pharmacists and pharmacy technicians, Manzi said.

On arrival, she assumed the role of managing pharmacist. Pharmacists with emergency department training who had been working upstairs in the hospital came downstairs to bring the total to six.

Shannon Manzi

Manzi said emergency care personnel organized into four teams, each with two physicians, two nurses, one clinical assistant, one respiratory therapist, and one pharmacist. She remained available to manage resources, ensure everyone had what they needed, communicate with the main pharmacy, and step in when a pharmacist needed relief. The sixth pharmacist worked with the patients who were in the emergency department for reasons other than the bomb explosions.

Brigham and Women’s Hospital, a level 1 trauma center next to Boston Children’s, received 31 patients from the explosions, an emergency department physician told CNN on Monday night. Nine of those patients underwent major surgery that day, he said.

Pharmacy services executive director William Churchill said his department’s immediate goal was to ensure that the physicians and nurses in the emergency department would not have to leave a bedside to obtain a medication. The pharmacy accomplished that goal by shifting resources to have six pharmacists in the emergency department in the initial hours after the explosions, he said.

One pharmacist was already in the emergency department for the evening shift. The day-shift emergency department pharmacist, Churchill said, stayed on, as did nearly all the staff.

And, “as luck would have it,” he said, several members of the “emergency department pharmacy team” were already on duty in other areas of the hospital. The pharmacy deployed two to each of the main areas of the emergency department. In each twosome, one spoke with the nurses and physicians to determine what they needed and answer questions and the other pharmacist expedited medication delivery.

“We drill a lot with preparing for disasters and mass casualties,” Churchill said.

In those types of emergencies, patients may need a medication before they have a medical record number or their name is known. Lacking that information, he said, personnel other than the pharmacists can have trouble obtaining a medication from an automated dispensing machine. So the pharmacy on Monday deployed pharmacists who could obtain medications quickly from automated technology, he said. Those pharmacists also facilitated the preparation and delivery of preoperative i.v. drug doses for the patients heading for surgery.

“One of the pharmacists said to me that it was her perception that . . . the nurses seemed to be relieved that the pharmacists were there as part of the team helping them,” Churchill said. All of this transpired while he was offsite.

John Fanikos, one of the pharmacy’s senior directors, assumed the role of the pharmacy unit leader and went to the hospital’s command center, Churchill said. “We’ve actually drilled and practiced that with all of my senior directors.”

With Fanikos in the hospital’s command center, Churchill said, two of the mid-level managers took roles in operating the pharmacy command center.

Contingencies

Erasmo “Ray” Mitrano

At Massachusetts General, interim chief pharmacy officer Erasmo “Ray” Mitrano made sure Balch had support in the emergency department—another pharmacist who could lend a hand and provide care to pediatric patients if any arrived.

Mitrano sent Lois Parker to the emergency department from the pediatric intensive care unit. He also had pharmacists elsewhere in the hospital remotely handle the workload that would have been Balch’s on a normal day. This, he said, freed up Balch and Parker to focus on the patients injured by the bombs.

Parker said she stayed in the pediatric emergency department to be out of the way until her assistance was needed. But no pediatric patients had arrived by 5:30 p.m., she said, when the hospital’s incident command center sent a broadcast e-mail stating that staff coverage was adequate enough for the day shift to leave. She checked with Balch, who concurred that Parker could leave.

Parker said she felt “pretty prepared” for the situation in the emergency department. The hospital has conducted disaster drills on a regular basis, and she participated in a tabletop disaster drill that was specifically geared toward pediatrics.

Emotional Support

The day after the bombs exploded, Manzi said, Boston Children’s held a debriefing for emergency department personnel. She said the hospital commonly holds a debriefing after a bad outcome. But the recent debriefing was held for another reason. The injuries on Monday were not the type seen every day, she said.

“When it’s in your background and it’s terrorism,” Manzi said, “it’s a different thing than when it was a very, very sad case of a motor vehicle accident or a shaken baby.”

Churchill estimated that 50-some pharmacists were at “The Brigham” when the bombs exploded. “People rolled up their sleeves and volunteered to stay and did whatever was necessary to get it done,” he said. “I couldn’t be more proud of that situation or my department.”

When interviewed two days after the bombing, Churchill said he continues to check on how his staff members are doing. “Hopefully, everybody’s going to do real well,” he said.

Parker, who said she was not directly involved in caring for any of the injured, said the bombing hit particularly “close to home” because coworkers could have been among the injured. “The Mass General has a fairly sizable team of people who run in the marathon, and they raise money for various programs at the hospital, including the pediatric oncology clinic,” she said.

Word of the bombing reached Parker soon after she and others had determined through the marathon organizer’s athlete tracking system that some of their colleagues were near the finish line. Balch said she sees “awful accidents” all the time, yet what she saw April 15 was different.

“The thing that most struck me,” she said, “is it was something that somebody did to people. . . . That’s what makes it most horrific for me.”

Three hours after the bombing, the Boston Police Department reported that three people had died. Local hospitals had received 176 people by 7 a.m. Tuesday, the department later stated.

–By Cheryl Thompson; reprinted with permission from ASHP News.

 

March 25, 2013

With Students’ Help, Pharmacists Reach Every Patient at Cleveland Clinic Florida

Front row, Diana Pinto Perez, Pharm.D., pharmacist, is joined by (from left) Lori Milicevic, Pharm.D., BCPS, pharmacist, and Eniko Balasso, Pharm.D., graduate intern.

ON THE HEELS of ASHP’s Pharmacy Practice Model Initiative Summit in 2010, Cleveland Clinic Florida (CCF) set the goal of giving all patients at the 155-bed academic institution the opportunity to interact with pharmacists as part of their care.

It was a lofty goal, one that would stretch the pharmacy department’s staff and resources.

In addition to the responsibilities they already had for conducting profile reviews, reviewing medication dosing, attending patient care rounds, and providing drug information, pharmacists would also take on conducting medication histories, performing medication reconciliation, and offering disease-state or discharge medication counseling on all patients.

They were clearly going to need help, and that help would come from pharmacy students.

Layered Learning Models for Students

Six months after the Summit, Osmel Delgado, Pharm.D., BCPS, cPH, administrative director of clinical operations and director of pharmacy services, and William Kernan, Pharm.D., BCPS, assistant director and PGY1 residency program director, traveled to Cleveland Clinic’s main campus in Cleveland.

At the Cleveland Clinic Pharmacy Practice Model Summit, they met with pharmacy thought leaders from prominent health systems and learned how other systems were incorporating PPMI recommendations into their practice models.

Osmel Delgado, Pharm.D., BCPS, cPH

Delgado and Kernan were particularly impressed with the layered learning models involving students at the University of Michigan and the University of North Carolina–Chapel Hill.

“We took their examples as lessons learned, and began to engage the colleges of pharmacies that we had affiliations with to see how we could accept more students,” Delgado said. “It took a good six to 12 months to refine and retool the ways we could create a valuable learning experience for the students, but also have them apply what they know in practice.”

Building On a Solid Foundation

CCF already had a progressive pharmacy program in which four clinical pharmacists would take on at least one student per month for introductory and advanced pharmacy practice experiences.

Under the new model, each preceptor would offer at least four rotations per month, and students would work as pharmacist extenders. The process begins with an orientation that covers the health system’s electronic medical records system, documentation practices, medication history and reconciliation processes, and disease-state and discharge education.

From left, student pharmacists Yesenia Fike and Pamela Silva (Nova Southeastern University College of Pharmacy, Class of 2013) consult about a patient’s medications.

After orientation, students provide hands-on care in rotation blocks up to three months long. The preceptors act as coaches, and they review and sign off on the students’ activities and patient notes.

“When students come to orientation, we tell them that they are crucial to the process and that we expect them to do what the pharmacists do and ask questions if they need help,” said Kernan. He added that the block rotations offer consistency across areas of care such as internal medicine, infectious disease, critical care, and anticoagulation.

“In each area, the students have to do medication reconciliation, provide discharge counseling, and answer patient questions about medications.”

Accessing Patient Charts

Under the old system, pharmacy students lacked individual computer access to the health system’s electronic medical records (EMR) and documentation system, which limited their ability to participate fully in recording care and tracking patients. That has since changed, according to Antonia Zapantis, Pharm.D., M.S., BCPS, preceptor in the program and associate professor at Nova Southeastern University College of Pharmacy, Fort Lauderdale, Fla.

“We felt it was crucial that students have access to the records and use the same systems and forms as the pharmacists, so that they could learn how to use these resources as part of providing pharmacy services,” she said.

The pharmacy informatics team reworked several aspects of the EMR and documentations systems so that students could put progress notes into patient charts. Pharmacists cosign the student notes.

Happier Patients, Better Outcomes

Thanks to student involvement in the hands-on provision of care, the pharmacy department has met its goal of providing every patient at CCF with pharmacist interaction. As a result, patient satisfaction scores on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) have risen steadily over the last four quarters.

“The feedback we get from patients is that they’re happy to know and learn about their medications,” said Martha Espinoza-Friedman, Pharm.D., BCPS, clinical pharmacist and preceptor in the program. “Those who were in other hospitals before coming to CCF were impressed. They haven’t seen this kind of care before.”

Jaime Riskin, Pharm.D., BCPS

The patients are safer, too, said preceptor Jaime Riskin, Pharm.D., BCPS, clinical assistant professor at Nova Southeastern University College of Pharmacy.

“The pharmacy caught errors and documented adverse drug events because of all the students out there identifying discrepancies. It shows just how helpful students can be if you give them the right tools,” she said.

Riskin added that having access to the EMR system allows students to follow up and see whether their interventions made a difference in a patient’s care.

According to Kernan, the program at CCF shows how there is nothing to fear by extending the student experience into patient care areas. “We found that when you add more students, it makes your job more efficient. If you train them and use them right, it works in your favor.”

Delgado is optimistic about the future—for the program, the students who participate, and the students’ future patients.

“We’re teaching students to inject themselves into the process at key times for the patient, such as discharge or any transition of care from acute to post-acute settings,” he said. “As pharmacists, they will ultimately understand the importance of their work across an enterprise-wide continuum of care.”

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September 28, 2010

Frontlines at Home

Illustrated by Matt Sweitzer ©2010 ASHP

SINCE 2002, more than 425,000 veterans of the U.S. wars in Afghanistan and Iraq have been treated by the Department of Veterans Affairs (VA). That is an average of 258 new patients each day. As the system struggles to cope with the demand for services, pharmacy clinicians are coming face to face with a veteran population whose needs are strikingly different than those of veterans of previous wars and conflicts. Today’s veterans are young, many of them present with co-morbidities that include a psychological component, and 12 percent of them are women—the highest percentage of females in the system to date.

If ever there was a time for pharmacists to use their training as care providers and coordinators in tending to the nation’s wounded, that time is now. Fortunately, they are prepared: Pharmacists have been playing an integral role in care at the VA—and

in the Department of Defense (DoD), treating active-duty military personnel—since long before the U.S. launched military operations in the two current wars.

“We’ve been at the forefront of clinical pharmacy practice and have had quite a sophisticated level of practice for many years, with pharmacist-managed clinics and pharmacists embedded in primary-care teams,” said Michael Valentino, R.Ph., MHSA, chief consultant, Pharmacy Benefits Management Services, VA, Washington, D.C. “Now we are moving into some areas that require additional staffing to enhance services, such as mental health. We’re also involved with specialty clinics and centers, such as the five polytrauma centers in the system.”

The day-to-day activities of a pharmacist at the VA or DoD depend on the size of the facility, whether the pharmacist is working

with inpatients or outpatients, and the pharmacist’s own specialty, he added.

In general, however, pharmacists are rising to meet challenges in several key areas: patient transition from active duty (treatment by the DoD) to veteran (treatment by the VA); mental health, particularly where there are co-morbidities; and women’s care.

Transitioning Patients

According to Valentino, whenever there are handoffs during a patient’s transition from active duty to veteran, there is potential for a glitch, mainly because the computerized systems at the DoD and the VA are not linked. Although both agencies are working on ways to rectify the disconnect, for now the transition requires pharmacists and other clinicians to do some legwork.

“The VA and DoD try to look at handoffs at the micro level, and the VA has in fact put some staff at DoD centers to help smooth transitions,” Valentino said. “Before patients are discharged [from active duty], they are advised about VA services and hooked up with providers.”

“Good patient handoff is critical,” said Lieutenant Colonel Eric M. Maroyka, Pharm.D., BCPS, pharmacy director, Fort Belvoir Community Hospital, Fort Belvoir, Va., and former U.S. Army officer in residence at ASHP. “We want to make sure that nothing gets dropped and that people don’t get lost to follow-up, with no one checking up on them for appointments and so on. We’re doing better at handing off information and plans to the VA and civilian sector.”

Mental Health and Co-Morbidities

Pharmacists who treat military personnel and veterans are seeing more patients who need behavioral health care than ever before. Part of the increase has to do with the nature of the current wars, said Maroyka.

“This is a tired military force with many of the combat troops getting deployed three or four times,” he said. “Over time, that can increase the risk of conditions like depression and post-traumatic stress disorder.”

Traumatic injuries such as loss of limbs and disfiguring burns complicate a patient’s needs, he added. “Initially, the person may seem okay with it and appear to be progressing,” said Maroyka, “but down the road, behavioral issues will trump all.”

Perhaps the greatest challenge comes from traumatic brain injuries, including concussions from blast injuries. Treatment then becomes a test of a clinical pharmacist’s skill and training.

“If there is a traumatic brain injury, then all bets are off, and you’re flying by the seat of your pants,” said Matthew A. Fuller, Pharm.D., BCPS, BCPP, FASHP, clinical pharmacy specialist in psychiatry, Louis Stokes Cleveland VA Medical Center. “You have to use what you know to treat the symptoms, especially if it is organic depression caused by head injury.”

He added that there is a dearth of published studies about patients in this particular population. “It’s frustrating,” said Fuller. “Trying to do research in that setting is next to impossible, and it is difficult to find supporting literature. We just don’t have it.”

“Co-morbidities are one of the biggest problems,” said Jennifer L. Mauldin, Pharm.D., clinical pharmacist at the James A. Haley Veterans’ Hospital in Tampa. “There are so many different specialists to refer patients to—the traumatic brain injury team, the psych team, the primary physician. I do a lot of medication reconciliation, making sure patients are on the same meds as outpatients that they were as inpatients.”

Mauldin noted the clinical challenges of co-morbidities. “For example, you might be inclined to give a patient a benzodiazepine for anxiety, but not if there’s a brain injury, because these drugs slow cognitive function,” she said. “On the other hand, a prescriber might order stimulants for a patient with a brain injury, but those can cause insomnia, which is not what someone with sleep disorders from post-traumatic stress needs.”

Patricia Oh, Pharm.D., clinical pharmacist at the Warrior Clinic of the Walter Reed Army Medical Center, Washington, D.C., said that co-morbidities present a clinical challenge to pharmacists in terms of coordinating care.

“One of the things we have to be proactive about is recognizing the signs and symptoms of co-morbidities and indicators of risk,” she said. “We’re part of a multidisciplinary team, and we need to be able to refer patients to their doctors or specialists appropriately.”

Oh noted the important role that pharmacists play in ensuring that patients and their caregivers understand how to manage patient medications.

“A lot of our work has been education,” she said, “whether it’s with the patients themselves or with their non-medical attendants,” such as family members, friends, or others.

Coordinating Care in Smaller Facilities

The James A. Haley Veterans’ Hospital has one of the five polytrauma centers in the VA system, which gives it a leg up on managing care for patients with co-morbidities. However, coordinating care can be more challenging in smaller VA facilities, such as the VA Sierra Nevada Health Care System in Reno, Nev., where Scott E. Mambourg, Pharm.D., BCPS, is clinical pharmacy coordinator and residency director.

“Here we have to coordinate that care with bigger medical centers,” Mambourg said, which results in interfacility VA referrals or fee-basis to private care, depending on patient need. “It requires a lot of communication, and important functions such as medication reconciliation and monitoring for outcomes and adverse events become that much more critical.”

Virginia Torrise, Pharm.D.

He added that it can be tough for patients in rural areas to travel to the medical center. Younger veterans in rural areas often turn to private, civilian care, which can create complications for co-managed care. In response, the VA is funding rural health solutions such as telephone care and community-based outpatient clinics.

“Some veterans come to us for the prescription benefits. They will present prescriptions written by private-care providers for expensive drugs, but prescriptions have to be written by a VA provider for us to fill them,” Mambourg said. “For the VA to take that responsibility, we would need the patient’s private records, and the patient would have to be enrolled in the care of a VA primary care or specialty provider for the prescribing and monitoring of those medications.”

Women’s Health Challenges

Every VA facility has a women’s health coordinator and women’s health clinic separate from the general clinic, and female veterans may choose which clinic to go to for care. However, the main challenge in meeting women’s needs is facilities-based.

“The VA just wasn’t set up for women’s health,” said Lt. Col. Maroyka. “VAs never really handled obstetrics and gynecology or delivered babies before. The facilities weren’t designed for it.”

Now, VA and DoD pharmacists are finding themselves having discussions with patients about genetic testing and counseling pregnant patients on the relative risks of pharmacologic treatment of depression.

“As the medication experts, we have to consider what is best for both mother and child, because the drugs can affect the fetus,” said Fuller, of the Louis Stokes VA Medical Center. “If the depression isn’t severe, we can point to cognitive behavioral therapy, without drugs, especially during the first trimester. Likewise, pregnancy pushes us away from certain anticonvulsants that can normally be used for traumatic brain injury.”

Roughly 10 percent of VA facilities have clinics geared specifically toward women’s mental health issues, he added. These programs employ specialists who focus on treating female veterans who have post-traumatic stress disorder, sexual trauma (which encompasses a broad range of issues from sexual harassment to sexual assault), and other mental health issues.

A Growing Need for Pharmacists

The wars in Afghanistan and Iraq have resulted in an increased need for clinical pharmacists and clinical pharmacy specialists who can support case managers and care coordinators, said Virginia Torrise, Pharm.D., deputy chief consultant for professional practice and clinical informatics, Department of Veterans Affairs, Washington, D.C.

“VA is embracing the principles of the patient- centered medical home, and we are recommending that there be a higher number of clinical pharmacy specialists available,” she said. “It’s a great opportunity for pharmacy managers to provide guidance for what staffing is required to adequately support the medication management needs of our veterans.”

Clinical pharmacy specialists in the VA can prescribe medications and order tests within the practice setting, an expansion of scope of practice that can benefit patients, according to Torrise.

“Our specialists are highly trained professionals working at the top of their skills,” she noted, adding that VA pharmacists often treat multiple chronic diseases in primary care. “Our physicians are recognizing the excellent care that clinical pharmacists provide and seeing how these referrals free up their time for more urgent clinical needs. Our veterans are entitled to the best care, and pharmacists are key members of the clinical teams to provide this care.”

Creating an Innovative IV Delivery System

THE STAFF AT WOMEN & CHILDREN’S HOSPITAL OF BUFFALO knows the value of speaking up. When it became evident that a new smart pump that Kaleida Health had introduced for use in its five-hospital system wouldn’t serve the needs of  Women & Children’s diverse population, the staff took its concerns to the administration. The result is an intravenous (IV) medication delivery system with a 99 percent compliance rate and real evidence of prevented errors. The system is so innovative that it won an ASHP Foundation Award for Excellence in Medication-Use Safety.

Kelly A. Michienzi, Pharm.D.

Preventing Workarounds

The smart pump Kaleida had originally intended to use wasn’t flexible enough for use with pediatric patients in particular, said Kelly A. Michienzi, Pharm.D., clinical pharmacy coordinator and co-chair of the hospital’s Pediatric Pharmacy & Therapeutics Sub-Committee.

“As we got deep into the software, we saw that it didn’t have proper dosing categories for pediatrics,” she said. “We knew it would produce too many workarounds.”

Rather than spend the money on a pump the staff likely would not use efficiently, the hospital gave the subcommittee permission to look into alternatives and develop an IV medication delivery system and training program. The staff recruited a multidisciplinary team for the task, including pharmacists, nurse educators, biomedical engineers, physicians, information technologists, and a toxicologist.

The team had several criteria for the new IV medication delivery system: It had to provide flexibility in dosing, include a customized drug library, and use

Michael Kalita, R.Ph., M.B.A.

wireless technology. At the time, the pump vendor was beta testing the Symbiq, and the team agreed to look at it.

“We saw immediately that the features were better for our needs. For example, it had a color monitor that was three or four times the size of the [originally proposed] pump, which is important for ICU physicians and staff running a code at the head of the bed,” said Michael Kalita, R.Ph., M.B.A., pharmacy director.

The more that staff members worked with the pump, the more ideas they had for fine-tuning its features, and soon the team’s feedback became integral to the pump manufacturer’s development efforts.

Collaborating for Safety

Michienzi said that input from the nurses who would be using the pump at bedside was critical, especially when the staff members loaded the library data into the pumps during pre-implementation testing.

“We asked them what they would do as well as what they weren’t supposed to do but might [given the pump’s features at the time], so we could try to find ways to prevent workarounds,” she said. “We asked nurses who have been here for 20 years, and we just kept playing with it until we got a library that everyone was comfortable with. It was a very informal failure mode and effects analysis.”

“You can’t have pharmacists build a drug library without nurse involvement,” said Kalita. “Nurses think about drugs differently than pharmacists, and you have to meet in the middle and come up with a system that works at the bedside.”

The team also developed a comprehensive training and education program that includes classroom education and hands-on training with the pumps.

Achieving Impressive Compliance

It wasn’t long before the effort put into developing the system bore fruit. During the first year of implementation, the number of preventable errors dropped 50 percent. Reports generated through the pump’s wireless technology attest to its 99 percent compliance rate.

The ASHP Foundation recognized the team’s efforts by awarding it the 2009 Award for Excellence in Medication-Use Safety. “What made this so impressive is that the pharmacist-led team had gone down a path to incorporate a smart pump as part of an IV medication system, found it wasn’t working, pulled a team together, and went to the administration,” said Foundation Executive Vice President Stephen J. Allen, M.S., FASHP. “At first, the technology was going to shape the care system, but the team said that the care system needs to shape the proper application of technology.”

The result is better care for patients, Allen added. “When you involve the people who will use a technology in making decisions about it, it yields improved quality and safety. The real change is evident at bedside.” Michael Kalita, R.Ph., M.B.A.

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