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Are you sure you are documenting in the right patient profile?

Right or wrong chart?

Performing a patient safety assessment at a busy physician office practice recently, I came across a documentation error that the inpatient arena has had considerable success tackling for years now, but which appears to be a commonplace occurrence for our colleagues outside the big house (meaning the hospital, of course).  The problem of entering information on the wrong patients chart (paper or electonic) has been handled in hospitals by practitioners requesting two patient identifiers and cross checking them with information on the patient’s paper or electronic chart.  Clinicians in physician offices do not appear to have embraced the practice to the same extent.

Thoughts on the Pew Prescription Project analysis of the U.S. drug supply


Plenty of opportunity for counterfeiters to inject unsafe drugs into the US pharmaceutical supply chain.

Firstly, I’d like to categorically state that this blog doesn’t do politics.  It is strictly concerned with promoting awareness of patient safety issues and to provide safety related best practice recommendations to professional and lay stakeholders.  Now that disclaimer is out of the way, I’d like you to cast your mind back to 2007 when 149 patients in the US died after receiving tainted Heparin originating from a Chinese manufacturing facility.  The cause was the addition of a cheap additive, Chondroitin Sulfate, which was also linked to the deaths of patients in Australia, Canada, China, Denmark, France, Germany, Italy, Japan, the Netherlands and New Zealand.

Last year, the Pew Charitable Trusts Prescription Project, which based on its project overview, does do politics, released its report “After Heparin: Protecting Consumers from the risks of Substandard and Counterfeit drugs”.  It was a good report in that it provided an indepth analysis of the current state of the U.S. pharmaceutical supply chain. However, some of its findings could be interpreted as being politically motivated in nature.  This is unfortunate since the topic at hand is an extremely important one.

Drug shortages: impact on patient safety

Drug shortages have hit hospitals and patients hard

In my days as a pharmacy director at a large medical center in the 1990’s and early 2000’s, I recall being increasingly alarmed at the number of drug shortages that I and my staff had to deal with.  The true impact on care of those shortages was not as apparent as it is with todays shortages where technology and sophisticated quality monitors help us calculate the impact accurately.  In the past, shortages were often due to over reliance on the just-in-time delivery model that many wholesalers and hosital pharmacies had just discovered.  Occasionally, a factory strike in Puerto Rico or a hurricane in the carribbean would disrupt the flow of a pharmaceutical product for a few weeks and that would be that.  Today, however, the reasons for drug shortages are far more complex, and because the environment of care is much more reliant on electronic drug identification and documentation (i.e., bar coding technology), the effects of even a very short lived supply disruption are far reaching and easily identified.  The number of drug shortages to hit mainstream hospital medications has reached epidemic proportions.  A matrix of factors that start with the overall economic malaise that has pushed some pharmaceutical companies to stop manufacturing certain drugs to unanticipated manufacturng quality issues to dwindling supplies of raw materials all play a part in the current state of affairs where according to a recent ASHP survey, 47% of large hospitals have reported shortages of 30 or more drugs in the past 6 months.

Tackling Alarm Fatigue: An opportunity to save lives

A delay in responding to a clinical alarm can be deadly

While assessing clinical practices and operations at a different hospital almost every week, I am often amazed at the ability of members of the care team to manage their duties and responsibilities in such a professional manner, despite the onslaught of so many competing priorities – give meds on time, document everything, attend care team conferences, and so on.  Of course, many nurses resort to taking short cuts and make decisions to prioritize various tasks over others in order to focus on what is important at that moment.  A casualty of this constant clamor to complete tasks, re-prioritize others and respond to  emergent issues is that alarms emanating from patient monitoring devices are often ignored.

Over the years, hospitals, the Joint Commission and the media have occasionally scrutinized the problem of alarm fatigue but the lack of constant diligence and focus has helped to make this an issue that remains a lower priority than it should be.  Any health professional that does not give due respect to this issue would do well to read the following blog post on the Findlaw.com legal information website making it clear that the medical malpractice community is fully aware of the impact of alarm fatigue.

Consumer medication safety: Crushing oral medications not always a good idea.

Mortar, Pestle... Hold the Crushed Meds.

People crush their tablets or open their capsules and crush the contents for a multitude of reasons; an upset stomach, bad taste, presence of a feeding tube, bariatric surgery or lap band placement, etc, etc.  It is important to be aware however, that unintended consequences ranging from the benign to mildly irritating to extremely dangerous side effects could result if one chooses to crush a medication without first determining the safety impact of doing so.  As with all medical or pharmaceutical questions, one should consult one’s doctor, nurse practitioner or pharmacist for the best advice, and follow up by verifying the information provided by researching the answer at a reputable online or published resource.

During the quarter of the twentieth century, many pharmaceutical manufacturers were able to formulate medications which were previously dosed multiple times a day in a manner that supported once daily dosing.  An example is the drug Theophylline, used for respiratory conditions such as COPD.   Many drugs can be taken once a day because the tablet/capsule is either designed to break down slowly and release the active ingredient through tiny microspheres or beads, or are coated so that they do not release the active ingredient in the stomach, where they might cause undue irritation of the stomach lining or where they could be inactivated by stomach acid.

The Thirty minute rule and timely administration of medications

An issue I frequently encounter while assisting hospitals in planning and subsequent optimization of barcode medication administration system practices is the difficulty that many organizations have in establishing and maintaining  practices related to administering medications on time or at the most clinically appropriate time.

A contributing factor is the so called “thirty minute rule” – the requirement in the Centers for Medicare & Medicaid Services (CMS)  conditions of Participation Interpretive Guidelines to administer medications within 30 minutes either side of the scheduled administration time.  See page 174 on the CMS site for more details.

Chance of a patient experiencing a medical error – 1 in 10; chance of a patient experiencing a medical error and dying – 1 in 300

These astounding, though not altogether unexpected figures, were announced by Sir Liam Donaldson, former Chief Medical Officer for England and current World Health Organization envoy for Patient Safety.  He compared these figures with the universal standard of unexpected deaths – namely those resulting from air crashes, which incidentally weigh in at one in ten million.

ASHP Shared Member Resources enables members to share documents on-line

Having relied for years on ASHP’s Listserv to share concerns and thoughts on pharmacy practice, I was especially pleased to see a new ASHP initiative designed to make the functionality of the pharmacy practice listservs it hosts much more valuable.  ASHP’s Shared Member Resources allows pharmacy directors, managers and practitioners the ability to share documents they have created at their individual practice settings with their fellow ASHP members.

For Patients: 20 Tips to help prevent medical errors

AHRQ (Agency for Healthcare Research and Quality) has published a patient fact sheet for consumers / patients outlining strategies for preventing medical errors.  The pamphlet, found here, contains much advice on managing accurate communication between clinicians, physicians and patients to help reduce the potential for medical errors.  The first three recommendations are copied below…

Death… By Powerpoint!

Ready for another exciting presentation?

We’ve all sat through them.  Some of us are even responsible for perpetuating them.  Powerpoint-fests are a staple of modern business and it is likely that we are stuck with them until the advent of a holographic surround sound/surrond animation method of imparting knowledge to a room full of workshop participants is developed.

This morning, en-route to Louisville, KY for a week that will end with what else, a big powerpoint presentation, I ducked into the President’s Club at Houston Bush Airport and relieved said establishment of a stale bagel and a copy of today’s Financial Times (US edition).  Therein, I was pleased to find an article written by my favorite management columnist, Lucy Kellaway, on the pitfalls of Powerpoint presentations.  You can read her article in it’s entirety here, but to summarize Ms. Kellaway’s thoughts, she points out that the economic impact of people sitting through powerpointfests is over one hundred million Euros per year.  The impact on the mental agility of those forced to sit through bad powerpoint presentations is not however calculable but she implies that attending such presentations may leave attendees unable to work as effectively as they might otherwise be able to.  Her assertion that powerpoint allows speakers with below average speechmaking ability to be more confident about their work is right on the money and is perhaps the most unfortunate aspect of reliance on the tool.