FORHEALTH TECHNOLOGIES CHIEF PHARMACY OFFICER CALLS FOR HOSPITAL PHARMACIES TO RETHINK USE OF TECHNOLOGY TO IMPROVE SAFETY IN IV DOSE PREPARATION

Relying only on paper labels and human diligence in pharmacy IV rooms is insufficient;
Identifies technologies that can and cannot reduce medication errors in hospital IV rooms

 

WHO:      Dennis Tribble, Pharm.D. Chief Pharmacy Officer for ForHealth Technologies and Chairman of the American Society of Health-Systems Pharmacists (ASHP) Section on Pharmacy Informatics and Technology. Tribble has more than 30 years of professional experience working in hospital pharmacies and has published extensively on hospital pharmacy operations and hospital pharmacy automation.

 

WHAT:      Tribble is calling on the hospital pharmacy community to increase its awareness of the technologies that exist today that can greatly reduce the potential for errors in hospital pharmacies.

 

Dr. Tribble comments: “Hospital IV rooms have been largely ignored when it comes to advancements in technology to improve patient safety. Pharmacists and IV room technicians deserve better technology for error prevention than paper labels and manual calculators. Incrementally adding more manual checking steps that rely solely on human diligence is not a viable answer.”

 

WHERE:      IV room errors made in preparing intravenous medication doses are among the most difficult to detect and potentially the most hazardous to patients. Intravenous doses are commonly given to the most acutely ill patients and often include the most potent of drugs.

 

“IV doses are generally mixtures of clear liquids – once mixed, visual inspection of doses simply cannot uncover errors. Human diligence is simply insufficient,” Tribble said. “In the course of their daily work, hospital pharmacists inspect hundreds, sometimes thousands, of IV preparations – the vast majority of which are correctly prepared. Finding the rare error amongst hundreds of correct doses stresses human capability. ”

 

HOW: What CANNOT fix the IV error problem?

• Adding more inspections by pharmacists and technicians does not promise a resolution. All human beings make errors at times. Adding more people performing more inspections may reduce error rates to some extent – but there can be little doubt that uncaught errors will continue to occur as long as human diligence alone is used.

• Modifications to container labeling - color coding, bigger type, etc. - is not the answer. The number of possible colors, special lettering approaches, etc. pales in comparison to the number of discriminations amongst labels a pharmacist must make. In the end, hospitals will still be relying on human diligence.

• New patient safety-centered technologies that do not impact IV room processes simply cannot impact IV room error rates. Examples:

  • Bar Code Medication Administration (BCMA, BPOC) systems use
    barcode-scanning to reduce dose administration errors at the patient bedside (i.e. administering one patient’s dose to another.)  However, BCMA systems are downstream of IV room processes and can’t detect or prevent errors made in IV dose compounding.

  • Computerized Physician’s Order Entry (CPOE) systems -- aimed at making sure physicians’ orders are properly entered and communicated -- are upstream of IV room processes and can’t detect or prevent errors made in IV dose compounding.

What CAN help fix the IV error problem?

• Carefully redesigned and automated workflows with in-process checks and controls that assure each dose reaching the patient is known to be correctly compounded. Automation systems are untiring and single-minded in their implementation of quality assurance.

• As a part of this process re-design, bar code scanning can and should be utilized in the IV room to reduce “wrong drug” errors.

• ForHealth Technologies has specifically designed dose preparation devices and bar code-based work flow automation products to reduce medication errors in hospital pharmacy IV rooms and provide pharmacists with desperately needed technology advancements.

Hospital IV room workflow technology from ForHealth can:

• Automate in-process verifications to ensure that correct products are     selected by the pharmacist or technician;

• Automatically perform dose calculations (versus the manual calculators used in most hospital IV rooms today) and provide confirmation “are you sure?” safeguards at every stage;

• Digitally photograph every step in the process to permit both prospective and retrospective control of critical steps in the IV room process.

• In addition, ForHealth’s high-speed robotic doses preparation systems prepare doses with consistent, repeatable accuracy that cannot be attained by human beings. ForHealth’s systems have prepared more than 22 million doses.

 

WHEN:           The technology to automate the hospital IV room and successfully reduce human error for as little as 25 cents a dose, is available today.