The Five Rights

Tube Tribulations

2010-06-12T09:09:00.000-07:00

I'd imagine almost every large hospital has a pneumatic tube system. If you walk around in the bowels of a hospital, you'll see the winding plumbing snaking overhead and hear the hurried distant bumping and ringing of a tube flying along on compressed air to it's next destination. If you happen to be a nurse working in a destination site, the hissing sound that precedes a loud "thump" as the tube drops into it's black receptacle is a audible signal that medications or supplies you ordered what felt like hours ago have finally arrived.

In many ways a tube system is like the London Subway system. There are various "lines" with transfer points between them. The transfer points mechanically move the tubes between various lines much the way South Kensington station allows passengers to transfer between the Blue, Yellow and Green Lines.

A pneumatic tube can only handle so much in the way of weight. Despite the fact that the tube will hold a liter bag of fluid, the weight of the bag can slow the tube in transit and wreak other havoc. The tube is the preferred delivery method for leg-weary delivery staff. Despite policies to "hand-deliver" certain medications, delivery personnel tend to push these limits.

Now one particular morning when I was working in our cleanroom, the staff was really upbeat. It was busy, but we were ahead for the day and nailing our deliveries on time. The phones were blissfully silent, a sign that we were on top of things. A recent batch of "banana bags" were dispatched to the delivery table, the first one was needed on the medical unit right away and I informed the technician who was manning the table of that fact. It was not my job to tell her to hand deliver the liter bag of fluid, that was policy, so I walked back in the cleanroom to check on more orders.

Within about thirty minutes, our fortunes changed dramatically. The phones started to light up with calls from angry nurses.

"I sent that order over an hour ago and I still have not received it!" she blared over the phone.
"Well, I'm sure that it was made and put out for delivery" I replied.

Over and over again, the calls started coming down hotly. I checked the delivery logs and saw all the medications in question were delivered - tubed to the destinations in question. Now it doesn't make sense to argue with nurses. We just duplicated the medications and had one of our cleanroom techs deliver the medication by hand. Surprisingly, they all came back with the same story "I couldn't find the original dose that was sent up.". It was a mystery. And to compound the problem, our supply of tubes was getting low. The delivery staff put out an overhead page to the hospital to send any empty tubes to the pharmacy ASAP. None came down.

The morning turned into a really bad early afternoon. It wasn't until after lunch when the guy from building maintenance came down to the pharmacy and asked me to follow him. I asked him where we were going and he said "the roof." Now for the life of me I couldn't figure out why we would be going there. When we walked out the access door to the roof, he said "Do these look familiar?" I was amazed to see almost 50 tubes laying scattered all over the roof, full of the medications we'd been sending up all morning long - now baking in the hot sun. In the center of the mess was a big sheet metal box - one of the tube transfer stations - with a giant hole blown in the top of it. "I expect this is the one that did it" he said holding up the now broken polycarbonate tube that reeked of multivitamins and had the withered corpse of a liter IV bag in it. "now you know why we have policies about tubing things like this! I bet these were flying out of that there hole like a fountain."

The rest of that week, we were not allowed to tube anything while they got the system fixed. And despite a lot of grumbling from the delivery staff, we had a lot fewer calls for missing medications coming into the cleanroom.

He said - she said... and the BLACK HOLE of pharmacy

2010-02-25T10:10:00.000-08:00

It's a very common problem in pharmacy. An order is sent down to the clean room for stat antibiotics. The pharmacist quickly enters the medication order into the pharmacy order system and labels spew out at a printer near the laminar airflow hood. A pharmacy technician is verbally alerted to the "hurry up" nature of the order and diligently prepares the life saving meds. They are checked by the pharmacist and set out on the delivery table to be sent up to the nursing staff.

High fives all around!! Team IV Room just saved a life.

Or so they think.

Thirty minutes later, a call from the nursing unit manager goes something like this.

Nurse: "I sent that order for Mrs. Jones down 30 minutes ago. It was clearly labeled STAT. I've been standing by the tubes and checking the med room - no drug. The family is very upset and the doctor is calling me to see that it has been infused. Where is it?"
Pharmacist: "We prepared that med in record time and had it on the delivery table in less than 3 minutes. It should be up there."
Nurse: "It's not here."
Pharmacist: "I sent it."
Nurse: "No, you didn't."
Pharmacist: "Yes, I did."
Nurse: "Do you want to take this outside..."

OK, so I exaggerate a bit at the end, but there is a palpable feeling of animosity in the air. The pharmacy staff, now feelings of celebration long gone, starts the process of duplicating the dose - an expensive proposition both in terms of time and money.

As a pharmacist, there were times when I was working in the IV Clean Room where I, personally, would hand deliver medications to nurses because the anger and distrust had mounted so high. Our personal as well as professional reputations were at stake.

Where did the drugs go? THE BLACK HOLE OF PHARMACY.

Patient transfers, meds delivered to old unit; delivery cart bumps on the gap between the elevator and the floor, meds slip into oblivion; delivery of meds by tube, routing number entered wrong and sent to central services... the black hole is endlessly sucking drugs, time and money into it...

Pharmacy Practice News dropped into my inbox yesterday and I read the last article in the journal wistfully. How I wish we had a solution like MedBoard to track down where the meds had gone. Read the article. Money, time and the reputation of our profession are at stake.

charles

Pharmacy 2.0 Session

2009-12-09T10:32:00.000-08:00

@ASHP Midyear... Excellent session. Thanks go out to John Poikonen, Todd Eury, Kevin Clauson and Danny Sands. My big take away: Get Evernote. NOW!

charles

Heading to Midyear

2009-12-04T09:16:00.000-08:00

Just finishing some last minute items at the office before heading down to Las Vegas tomorrow. It's going to be a busy convention, as usual. I doubt I'll have much time for the tables (even if I had the inclination to gamble - which I don't). I will be in and out of our company booth during the exhibit hours (11AM - 3PM Monday and Tuesday, 11AM - 2PM Wednesday). Make sure and stop by to say hello if you are there.

I will be attending a number of sessions throughout the days and posting thoughts to the blog as I get access.

See you in Vegas!

charles

UPDATE: Oh, I guess I should mention the booth number: Pharmacy OneSource is in 830

10 Years After...

2009-12-03T09:51:00.000-08:00

There is a lot of content being generated about the 10th Anniversary of the IOM To Err is Human report back in December 1999. As I sit and listen (seriously, click the link and listen while you read the post!) to "I'd love to change the world" by Ten Years After (yes, I'm a child of the 1960s and 70s), I feel like the words ring home in so many ways the IOM probably didn't ever consider at this place in time... And I'm sure Alvin Lee wasn't thinking about healthcare reform when he wrote the classic lines:

"I'd love to change the world, but I don't know what to do. So, I'll leave it up to you."

"So, I'll leave it up to you..." The IOM wanted to change the world, but who is going to do it? Who is the "you?" It's Us!

Robert Wachter from UCSF just published a follow up report in Health Affairs where he gave us a B- on our efforts to solve the problems of health safety. As he notes on THCB, this is a minimal improvement from the last grade he gave us (C+) at the 5 year mark. The improvement in scores was due to increases in public reporting, improvements in safety enterprises within healthcare organizations and the establishment of "never events." Alternatively, healthcare IT has made "little progress... particularly when you contrast it with the breathtaking progress we’ve made in IT in virtually every other part of our personal and professional lives."

Why has healthcare IT had such a ho-hum effect on overall patient safety? Part of it is our expectations - IT viewed through the rose-tinted, round glasses of the Flower Power decade. A few weeks back, WSJs HealthBlog quoted one doctor saying that we have "magical thinking" (as in Magical Mystery Tour?) when it comes to health IT. According to him, our expectations that implementation of health IT will finally "save healthcare" is just plain wrong - and born out by studies. To be fair, targeted, judicious IT efforts can deliver exceptional results - when they are done right. But many IT projects are just to large to provide the focus needed to be successful. Another problem: the focus is on installing software, not delivering results.

This focus on results was another topic WSJ HealthBlog tackled this week. In this article, the incentives to reduce re-admissions were examined. I think everyone in healthcare would view re-admissions, especially shortly after discharge, as an indication of failure in some basic part of the process - a negative result. But the incentives for payment do not see it this way. Providers are paid for each admission. Reversing this incentive would provide impetus to focus on follow up calls, discharge counseling and preventative care outside the hospital.

"I'd love to change the world..." I think I have some ideas what to do

~charles

I'm back!

2009-12-03T09:50:00.001-08:00

Sorry for the long delay in posts... way too much on my plate, both at work and home. I am planning on getting back on the blogging wagon full force starting now!

~charles

Our patients

2009-10-07T14:55:00.001-07:00

This was an email I sent to our team at Pharmacy OneSource. When we work in healthcare (vendor or provider) we make a difference in patient's lives. Every email, every phone call makes a difference.

Hello everyone-

I just finished up a presentation with a group of 30 hospitals. I was demonstrating Accupedia to them. In the PowerPoint, I included an image of a patient in the Pediatric ICU at a hospital. It will be somewhat shocking for those of you who have not been in a hospital before or have limited exposure to patient care.

This patient is very sick. They are ventilated (breathing machine) with at least 5 infusions, some medication-laced. They are fully monitored. They invariably have an indwelling urinary catheter, probably 2-3 IV lines in, at least one directly into the heart. There is a tube into the patient’s stomach to drain away the acid. The bed is a large oscillating balloon designed to prevent pressure ulcers. The noise and chaos this represents is what our customers deal with on a day-in and day-out basis. Not to mention the impact on the patient. And the family.

The reason I share this is that it is easy to forget what the impact of our efforts TRULY mean sometimes. Let me draw the lines:

We help someone setup Simplifi797 so they can more efficiently document and manage their IV Clean Room. The efficiency gained by using Simplfi797 ensures that all the proper cleaning solutions are used to keep the prep areas sterile. The IV bag you see hanging in the picture was made in a pharmacy clean room. If it contained ANY bacterial contamination at all, this patient would probably die.

We write a line of code for Sentri7 that makes it easier for a pharmacist to monitor for a drug this patient is taking that can lead to kidney failure in patients who have poor kidney function. This patient’s kidneys are only running a quarter as good as normal. The pharmacist detects this issue in Sentri7 and makes a dose adjustment that spares this patient from going on a dialysis machine.

We help someone with a question about Unit Stock trend reporting. Because of the better understanding of how to run a trend report, a pharmacy manager notices that this ICU has had problems with outdated medications in their floor supply. A pharmacy technician was dispatched, did a unit inspection on this floor and pulled a set of outdated atropine vials 2 days ago. This patient just got a dose of atropine 15 minutes ago… that was fresh and not expired. The expired med might not have worked properly and the patient dies.

We all do VERY important things here. Things we should all be proud of. I know I am.

~charles

Where did I go??

2009-10-05T13:57:00.000-07:00

I've been a little distant recently. I wanted to let everyone know the reasons.

I have been co-writing a textbook chapter for APhA and this has consumed all of my spare "writing time" over the last few weeks.

The chapter is due in a few days, so the final push is on. Once complete, I will be back at the blog full time. Stay tuned!

~charles

USP 797 Webinar Today

2009-09-02T07:46:00.000-07:00

The company I work for is sponsoring a FREE webinar today on how to use a GAP Analysis tool to identify weaknesses in your compliance with USP 797. There are limited spaces available. Reserve your spot now.

USP 797 was a landmark set of regulations to improve the safety of patients who receive sterile products compounded by pharmacies and others. Eric Kastango is a leader in this area and always an engaging speaker.

The session will be recorded. I will post a link to the recording tomorrow if you cannot attend today.

~charles

Healthcare Informatics Comment

2009-08-31T08:50:00.000-07:00

I just read a great post on Gwen Darling's blog at the Healthcare Informatics site. She proposes that blog commenting is a new skill for building your personal brand. I wholly agree! My comment is replicated below. See original blog post and comments HERE

=================================

"We just hired a new CTO at the company I work for and I know for sure part of the hiring decision was his personal credibility due to blogging and commenting activities.

You can assist the "Nancy Drews" out there by keeping your own professional blog and posting the comments you make in other blogs to it with links back to the actual comments. For example, when I post a comment (like this one!), I drop a post in my blog saying "I just left a comment at..." and provide a link back. This creates an easy to peruse record of your commenting activities. It only takes a click for a Nancy Drew to validate that, yes, you did make the comment. I Tweet every comment as well.

And this isn't the time to hide behind strange pseudonyms. If you are building a personal brand, you MUST use your real name. And if you are using your real name, you MUST say things that competent, credible and fair. Remember, it is YOU.

Great post Gwen!"

===============================

~charles

Patient Falls: Can Pharmacy Help?

2009-08-26T13:25:00.000-07:00

There is a wonderful post on The Health Care Blog today about patient falls, truly a national tragedy of preventable injury. To quote the authors "One in three adults 65 and older falls each year and every 35 minutes someone in this population dies as a result of their injuries..." According to the blog post, this results in a cost to the health care system of almost $55 billion a year. Ouch.

And it touches many lives. My own great grandmother, a spry lady well into her upper 80's and driving a Dodge Charger (as my dad would so aptly noted, "like a bat outta hell..."), fell at home, was admitted to a local hospital for a broken hip and was dead two weeks later from complications of hospital-acquired pneumonia. This happens far too often.

Where does pharmacy fit into this?

One of the primary risk factors for falls is medication use, specifically, medications the cause or exacerbate motor instability. There are some meds that wouldn't come to mind. CNS agents (narcotics, benzodiazepines, anticonvulscents and the like) are commonly known. But what about cardiovascular agents? Antihypertensives can cause dramatic syncope and lead to destabilization and loss of motor reflex. Couple these drugs with a sleeper and a pain-killer and the results can be devastating.

Can pharmacy really make a difference? The simple answer - YES, IT CAN. In 2003, Haumschild et al published an article in AJHP (Am J Health-Syst Pharm. 2003; 60:1029-32). They identified elderly inpatients on one or more medications known to increase incidence of falls by running a simple report out of their drug delivery systems. This report was delivered to nursing staff daily. Nurses then used this information to institute fall precautions in higher risk patients. The outcome? A 47% reduction in fall rate.

The key to this system is having a proactive, simple medication surveillance system in place (shameless plug) like the one my current employer has developed.

So what drugs does one look for? Basically anyone over the age of 65 on one or more medication classes found HERE. It's not an exhaustive list, but a good place to start. Another great overview of the problem by the CDC can be found HERE.

So let's have it in the comments. Do you have a proactive fall prevention program going on at your hospital? Have you been able to quantify the outcomes of the program?

~charles

The Last Touch...

2009-08-19T05:21:00.000-07:00

I read a recent report by the New England Health Care Institute that, while an eye-opener, wasn't a real shocker. The bottom line: Medication non-adherence (patients not taking their medications as prescribed) leads to $290 BILLION in additional health care costs due to treatment failure requiring additional outpatient care or hospital re-admission. This is 13% of our overall US health care expenditure! Patients with complex medication regimens (primarily patients with chronic conditions and multiple co-morbidities), elderly and poor patients made up the bulk of patients.

Pharmacy school teaches us that medication compliance is one of the most important aspects of pharmaceutical care. The pharmacist is the "last touch" in the health care system before the patient is sent into the wild on their own. Every state has counseling requirements. Why? Because it is critical that the patient understands how to take their medications (for the long haul in chronic conditions) and the ramifications of NOT taking them as prescribed.

But my own experience at the local pharmacy has been less than exemplary. I don't usually tell the staff at my local mega-chain that I'm a pharmacist. A harried technician asks me as she hands over the bag covered in patient leaflets if I want to talk to the pharmacist about it. The pharmacist glances over at me with a look of desperation, dishevelment and weary - my "last touch" with the pharmacist left me no better informed and just with a feeling of pity for him. The Pharmacy Chick Blog has a very poignant take on why this may be the case

My former hospital's discharge pharmacy wasn't much better. In the morning, as many patients were being discharged, a line would form outside "the window." A line of angry patients that wanted nothing more than to get out of the hospital and get home to recover. The counseling was rushed, cursory and minimal. Guaranteed, no matter how good the hospital stay had been, no matter how friendly the nursing care, this "last touch" tainted the entire experience in the mind of the patient.

Can pharmacy make a difference here? Clearly, it can.

The NEHI report mentioned above goes on to identify that when proper counseling is done, both at discharge and during a retail pharmacy experience, medication non-adherence improves by 40+%. This is identified on surveys to patients post discharge and could be subject to reporter bias.

A more concrete example of the value of discharge counseling and targeted follow up was presented at the ASHP Summer Meeting this past June. This presentation showed that when pharmacy takes an active role in the discharge process, medication failure related re-admissions fell dramatically. In fact patients in the control group (only cursory required counseling given with no follow up phone counseling) were 2 and 4 times more likely to be re-admitted for ADEs at 30 and 60 days respectively. They targeted the "at risk" patient groups identified above for specific post-discharge follow up calls. Just calling and checking in with patients had a huge impact on re-admissions.

The Obama administration is making it clear that being re admitted for the same medical issue is in the cross hairs for health care reform. The pharmacy profession has a real opportunity to show some value and push for medication therapy management. The evidence is behind us!

What do you think? What would your patients say about their "last touch" with your pharmacy services? Leaving comments is FREE!

~charles

Why is pharmacy the forgotten profession?

2009-08-10T06:58:00.000-07:00

Ahhh... vacation. My last week was spent traveling to the Oregon Coast with the family. Despite the self-imposed separation from all things work, I could not help but pick up on a couple items...

As I loaded our van last Saturday for the long drive, I had NPR playing in the background. Scott Simon was interviewing former Clinton-era HHS Secretary Donna Shalala. You can see her interview HERE. Despite her keynote address to ASHP at the Summer Meeting in 2006 where she indicated that pharmacy is a key "team player," she seems to have forgotten that pharmacy even exists. "We have lots of specialists in the country. We'll need more primary care physicians," Ms. Shalala told Mr. Simon. She went on to say "With all the advanced-practice nurses that we have in this country and more to be trained, there is a special role for nurses in our expansion of health care for all." Despite the fact that more errors are attributed to drugs than any other aspect of health care and the cost of medications continues to rise dramatically, pharmacy isn't even mentioned in the current debate.

During our stay in Newport, my wife and I went out to dinner at a small hotel restaurant called The Table of Contents. The Sylvia Hotel is themed on great authors, each room is set up in a style that calls out to a great writer. Dinner is served "family-style" at large tables with other guests and conversation is expected. There is no menu - you eat what is offered. The topic of health care reform came up at the table and many comments were offered. I mentioned that I was a pharmacist. I always do this as a test. "Where do you think pharmacy fits in in the health care reform debate?" I asked the table. The "huh?" look on people's faces was a dead give away. They have no idea how the guy behind the counter at Rite Aide has ANYTHING to do with health care reform. And I'm not picking on retail pharmacy. They didn't even KNOW pharmacists worked in hospitals!

This is a sad state of affairs. For the profession of pharmacy to have any kind of national impact at all, we need the public (and our elected officials) to recognize that we have an important role as credible health care providers. Medications can be safe. Medications can be cost effective. Pharmacy is at the front-lines of health care for most Americans. We need to step out of the shadows and assume the responsibility for taking care of people! Our professional organizations are not doing us justice in terms of PR. We need to take this matter into our own hands. The time could never be better - health care is on everyone's mind right now. Do you let your neighbors know the value you provide? Have you written your congress people about the value of pharmacy in health care?

~charles

Can technology alone cure health care?

2009-07-30T14:40:00.000-07:00

Excellent article on The Health Care Blog called E-Health - It All Depends on How It's Used . I added my comments to the mix.

"As a practicing pharmacist, I saw both sides of this issue...

On one hand, as the article so adeptly pointed out, we would see new technology introduced, cursory training would ensue and then we would be thrown into the same workflow models we had before. No effect would be seen at all on patient outcomes and cries "user error" and "why don't they get it" would ensue from the powers on high.

On the other hand, I attended numerous "efficiency programs" (some of which had the Toyota name liberally sprayed all over them) all with a focus on building out our ability to do more with less, create value, increase our throughput and potency as clinicians. We would then go back to our jobs, documenting our actions on scraps of paper so we could remember who we cared for and what we did the day before...

Technology alone will never solve the problem. My dad always said (and I'm sure he wasn't the first) "You can buy a fancy hammer, it sure as hell won't build a house for you..." Work flow redesign and technology integration, when married together in a thoughtful way, can have huge positive impacts on patient care."

~charles

Quoted in Infection Control Today

2009-07-27T08:06:00.001-07:00

I am a strong believer that health care is not an individual sport. To solve the major hurdles ahead of us, all clinical disciplines need to work together. Microbial resistance, over use and inappropriate use of antibiotics are major problems that a closer working relationship between infection prevention professionals and pharmacy can only improve.

To that end, I recently added my comments to an article in Infection Control Today about the use of clinical surveillance and decision support tools in this area.

Do you know your infection preventionist? Are you working together in synergistic fashion to leverage both of your effort to help patients? If you have tell us about it in the comments!

~charles

New to the Site: Blogroll

2009-07-25T09:58:00.000-07:00

I just added a blogroll widget to TheFiveRights Blog. This will give you direct access to some of the blogs I track daily. I find the opinions expressed in them valuable, even if I don't always agree. Here are my reasons for inclusion:

Lifehacker: An excellent site for personal, technical and professional productivity hints. One of the most popular blogs on the Internets. Their tagline says it all "tips and downloads for getting things done..."
Modern Healthcare: This is what your CEO is reading... shouldn't you be reading this too??
ASHP News Capsule: What issues does our profession think are important?
WSJ Healthcare Blog: Some of the best coverage and commentary realted to overall health care issues
~synthesis~: Not healthcare, but mind expanding political and global thinking. Shafeen Charania gets the big picture. Worth a read. I wait on his every post...
Healthcare Informatics: If medicine in general and pharmacy in specific has any hope of improving quality and efficiency, it will be on the back of advanced information technology. This is where to find the latest.
Pharmacy Informatics: John Poikonen is one of the pharmacy profession's "Chief Informatics Officers." His comments on the latest in pharmacy informatics are always relevant.
The Technium: OK, this is really not healthcare related... but if you want to really see some forward thinking on where we as a human race are headed, Kevin Kelly, the former editor-in-chief of Wired magazine's Technium blog is incredible. I'm an "idea guy" and can't wait for the next installment to blow me away. How forward thinking is Kevin Kelly?? He has a 2-letter domain website!! (www.kk.org) I rest my case.
The Blonde Pharmacist: I've tried to find pharmacy specific blogs that don't sound like people who hate the profession... Everyone has an opinion, I don't always agree with hers, but I choose to follow along.
The Health Care Blog: By far one of the best blogs about health care on the Internets. If you care for patients, this is a must read.

So this is it for now. I will update as I see the need. I am always looking for good health care realted blogs, people with opinions, willing to share constructive ideas. If you know of someone I've missed, make sure and drop them into the comments.

~charles

Pediatric Medication Safety

2009-07-21T16:02:00.000-07:00

Next week, July 28 from 12-1PM Eastern, Pharmacy OneSource (my day job) will be hosting a webinar on Pediatric Medication Safety. It is free! I encourage you all to sign up: https://www2.gotomeeting.com/register/788883355

The presenter will be Elora Hilmas, PharmD, BCPS. She is currently the PGY1 Residency Coordinator at the Alfred I. duPont Hospital for Children in Wilmington, Delaware. She graduated from University of Maryland School of Pharmacy and completed her PGY1 and Pediatric PGY2 residencies at The Johns Hopkins Hospital in Baltimore, Maryland. Elora has presented three times at the Annual Maryland Patient Safety Conference and has taught a lecture in the Medication Safety Elective offered at the University of Maryland School of Pharmacy. She is a co-inventor of Pharmacy OneSource’s Accupedia product and has won a Healthcare Hero award in the category of Advancements in Health Care from the Baltimore Daily Record for her work on standardizing concentrations.

I wrote a recent newsletter for work and re-print portions of it here:

It does not take much in the way of web searching to identify what a problem pediatric medication safety presents to health care. In an April 2008 Sentinel Event Alert published by The Joint Commission, Stu Levine from the ISMP is quoted saying that inpatient pediatric adverse drug events are three times more likely than adults in the same population. The report goes on to state that, in another study, a rate of adverse drug events in pediatrics was on the order of 11%. The Joint Commission publication goes on to list risk reduction strategies to prevent these tragic events. Our most vulnerable patients need our most rigorous attention and care.

A report last week out of Johns Hopkins underscores that the problem of pediatric medication safety is still very much with us. In their analysis of 821 pediatric medication errors, they found that half of these were in patients less than 1 year of age, 90% of these in patients less than 6 months. "The most common causes of dosing errors attributed to misinterpretation of the patient's weight, mathematical errors of computation, misinterpretation of orders, giving extra doses or missing doses." They go on to indicate that technology can improve safety by including double- and triple-checks into the systems.

Pediatric medication safety is still a very big problem. The margin for error is just too small.

~charles

A new start, and purpose

2009-07-17T06:37:00.001-07:00

I'm starting out again... After re-thinking the purpose for this blog, I've decided to rename it. The original name, Health Care Experience, seemed too broad and ambiguous. The new name, The Five Rights, is a common phrase in health care quality improvement circles. It has to do with medication safety - Right Drug, Right Patient, Right Dose, Right Time and Right Route. While this is far from all the aspects of the medication use process, it captures the essence of the issue and my passion.

Why medication safety? I've witnessed the problem first hand. Many years ago, I was a pharmacist at a large urban hospital in Seattle. We cared for children undergoing bone marrow transplant. One morning, I came into work, and the mood was very somber on the nursing unit I worked on. Usually friendly staff averted their eyes from my gaze... what was going on?? I found out quickly that there had been a re-admit during the night. A little girl, 8 years old had been given a mis-filled prescription by our outpatient pharmacy on her way home the day before. Rather than the mild antibiotic she was supposed to receive (doxycycline), she was dispensed a powerful tranquilizer (doxepin). After only a couple doses, her parents knew something was wrong and rushed her in.

Despite the fact I personally had nothing to do with the error, I took it deeply to heart. I felt terrible, responsible in some way. The rest of that day, I did everything in my power to help the family. I took the front end role as the face and heart of the pharmacy in their eyes. In the end, the parents were very understanding and the girl only had very mild and temporary symptoms. We dodged a bullet.

From then on, I realized what the possible impact of an error in pharmacy means. We do not come in to work in the morning thinking "I'm going to make a mistake today." Why do the systems fail us? What we now call casually a "LASA" error ("Look Alike Sound Alike") was allowed to proceed to patient harm. I can put an 8-year old girls face to it. In fact, there were few, if any "systems" in our pharmacy to handle such an event. Human error, inevitable, was not accommodated and mitigated in the technological systems people worked within.

So the focus of the blog will be medication safety. How technological systems can support it. How pharmacy clinical activities support it. Despite all our efforts, there will always be more to do. Because health care is ultimately a human system and will, by definition, be error prone. I've seen it. The cost is too high...

~charles

The Highest Level

2009-04-14T07:15:00.001-07:00

OK... sorry for the delay getting started here, but other pressing matters reared their heads.

For this post, I wanted to give people a general overview of our big complicated healthcare system in the US. And it is big... and complicated... So how to do this in a simple couple paragraphs?

First start with these statements basically culled from wikipedia (where you can find the references for the comments I'm making)

The United States is the only industrialized nation without national healthcare (we provide and pay for care through a hodge-podge of public and private entities)...
We spend more per capita on healthcare than any other country in the world (according to the government, in 2007, the U.S. spent $2.26 trillion on health care, or $7,439 per person)...
According to the World Health Organization (WHO), the healthcare we receive is mediocre at best (in 2000 the U.S. health care system was 1st in terms of responsiveness and expenditure, but 37th in overall performance and 72nd by overall level of health (among 191 member nations included in the study)...

So let's take each of these three topics as a post over the next few days...

Starting with the players in the healthcare system and how they relate to each other. These are the key players

Providers: Provide the actual hands on-care
Payors: Pay for the care given
Vendors: Develop and sell the technology that supports care
Overseers: Watch over the quality of care provided

Providers include: Hospitals (which can be public or privately owned; for-profit or not-for-profit; teaching or non-teaching; rural-, community- or big city-based), Specialty Care Clinics (such as Surgery Centers, Urgent Care Clinics, OB/GYN and others) and Long Term Care Facilities (including all sorts of nursing homes and rehab facilities, including hospice care centers). We also have non-public governmental provider systems (VA, DoD and Indian Health Service - all of which include hospitals, clinics and long term care facilities)

Payors include: Government-run insurance programs (Medicare for the elderly and Medicaid for the poor), private insurance (much of which is paid for by employers) and charity payors.

Vendors include: all entities that provide the tools, equipment, software, medicine and nutritional support products to make the system work.

Overseers include: governmental and non-governmental organizations tasked with accrediting, policy-setting and generally ensuring the quality of the system. There is a whole alphabet soup of these organizations. The key ones are:

JCAHO - Joint Commission for Accreditation of Healthcare Organizations
CMS - Centers for Medicare and Medicaid Services
USP - United States Pharmacopoeia
AHRQ - Agency for Healthcare Research and Quality

So this gives you an idea of who the players are. Next post will look at how these players interact...

-Charles

The Plan

2009-04-01T14:10:00.000-07:00

So, first of all, I am pretty blown away by the positive reception to this blog. Right after I announced it, I got a ton of emails from colleagues indicating what a good idea this was. Should have done it sooner...

So here are my thoughts: We are going to start this out kind of general and work our way into more and more detail. Some of the early content will be well-known review to many of you. Some of you have probably heard some of this and didn't want to ask questions because it seemed "dumb" to ask... So for those of you with healthcare knowledge or experience - bear with us while we go over some fundamentals. Help us all with your knowledge in the comments! Let this be a conversation. For those of you just getting to know our healthcare industry, please ask questions. We'll all be the better for them.

So an agenda:

Healthcare Systems & Organizations
Healthcare Financial Incentives
Who are the people in healthcare and what do they do?
Pharmacy - inpatient and outpatient
Clinical Initiatives
etc...

This might just cover the background essentials and may take a few weeks to get through. I reserve the right to vary from this if it seems like questions lead us there... Please let me know how you feel about the progress we are making.

I'll be off for the next couple days. We'll get started in earnest next week.

~charles

Resurrection

2009-04-01T09:23:00.000-07:00

It clearly has been a while since this blog was used. The main reason for resurrecting it is to build knowledge for my co-workers, but the information is of a general nature that should benefit anyone who has an interest in the clinical nature of pharmacy.

My intent is to publish on a weekly or more frequent basis. The topics being posted will be gleaned from current uses of our products. The focus (initially) will be on clinical pharmacy practice. What are the aspects of clinical pharmacy that lead to improvements in medication safety, reduced risk to patients and least cost to the system? My hope is to take a topic - a surveillance rule or an intervention type - and outline the whys, whats, whos etc...

If you have ideas for posts, please put them in the comments.

I'm looking forward to this!

~charles

The healthcare experience - first post

2008-05-07T14:42:00.000-07:00

Healthcare experience today... it's a complex topic. Much of the current focus in healthcare is on the quality of care delivered to patients - not a bad thing. But for vendors of software being developed to deliver the clinical care to patients, it is critical to document and disperse the experiences of healthcare providers. How do they use data? What data is used to make decisions? What are their work flows like? What makes their day difficult? What makes it easier? This blog will document and publish experience data that can be used in the design process of applications and process improvement efforts in the healthcare environment.

I am specifically doing this for the company that I founded and am currently employed by as VP Clinical Affairs. As the company has grown, we find that domain knowledge is becoming more dilute. This is my effort to encapsulate this knowledge in a form that is readily distributable and can be addressed and commented on openly. While I have knowledge of these domains, I do not claim to be the expert in everything. Where I can, I will link in content and bring in expert comments to supplement the issues being brought forward.

I hope this effort proves fruitful...

Charles