Device prevents errors in compounding meds
Program can't rely on human visual checking
A device tested at the University of Michigan Health System was 100% accurate in identifying the proper formulations of seven intravenous drugs. Health system officials say the table-top device manufactured by ValiMed, a division of CDEX, Inc., Tuscon, AZ, averted five potentially serious medication errors over an 18-month period at the University of Michigan's C.S. Mott Children's Hospital. Hospital officials said the university system is the first in the world to use the device to test patient drugs compounded in the pharmacy.
"Errors in compounding these types of medications are rare," said University of Michigan College of Pharmacy associate dean of clinical sciences Jim Stevenson, PharmD. "However, when they occur they can have a significant negative impact on patients and staff. We know from having this technology in place that we've deterred five errors that might have happened. I really believe having technology like this needs to be the standard around the country."
The ValiMed device uses enhanced photoemission spectroscopy to determine if the compounds are correct. In the process, light is shot into the drug compound, exciting molecules, and the energy emitted by the excited molecules is measured by a spectrometer. Each drug compound tested has its own "light fingerprint," which is compared to the fingerprint of a control compound. If the fingerprints match, the drug is considered to be correctly compounded.
"Our goal needs to be to have zero tolerance for errors," Stevenson said. "If we wanted to eliminate errors completely, we knew we couldn't continue to rely completely on human visual checking. We needed to implement some sort of technological solution to overlay our human process for these drugs to be fail-safe."
The hospital tested 40-50 samples daily, at strengths and variations above and below the proper dosage amount. Since the process only takes a minute, they were able to integrate the technology into the pharmacy workflow when using it for select high-risk products. The device is now used at University Hospital in addition to the children's hospital.
More 'fingerprints' needed
The application was developed after Stevenson learned that a colleague was using a similar device to test narcotics being returned in the operating room. He contacted the company about developing applications to check intravenous drug compounds prepared in the pharmacy for accuracy. The next step, Stevenson said, is for the company to develop more fingerprints so more drugs can be checked.
Meanwhile, the Institute for Healthcare Improvement cited Contra Costa Regional Medical Center in Martinez, CA, for its successes in reducing medication errors. The hospital formed a team of physicians, nurses, pharmacists, and pharmacy technicians who met for 45 minutes every week for two and half years. The team audited medical charts and found that in 26% of cases, a medication a patient was taking at home was not mentioned on an admission form.
They designed a form for doctors to complete with boxes to check for each home medication, showing whether it should be continued, discontinued, or modified during the hospital stay. The form becomes part of the medical record so nurses and physicians don't have to hunt through files to determine a patient's medications.
Quarterly hospital medical records audits have shown the percentage of home medications not mentioned in admitting orders has dropped to 1.1%.
After implementing the program in admissions, the team set up similar procedures for in-hospital transfers. Physicians no longer can just write "continue previous orders," but must specify drugs to be administered.
And there is a form for physicians to fill out listing which medications should be taken after discharge, including the dose and timing.
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