Post Order Chaos

I recently decided to look back at all my blogs I have currently written and I realized something!  If I were an average individual reading my posts I would think this writer is all over the place!!!!! I wrote my posts in the order that I noticed different aspects of informatics in the hospital, but these topics definitely do not reflect the way an individual should learn about the topics I posted.  If you are new to pharmacy, I suggest that you at least read the following posts in this order:

1. What is informatics?
2. The Amazing MPI
3. DOSEEDGE
4. Pyxis
5. Nurse-to-Pharmacy communication

[All of the articles are independent factors of the pharmacy that don’t require any real sequential reading….as of right now ;-)]

If you have not read my posts already, I highly suggest that you read the previous ones in this order so you can understand how all of these functions intertwine. BUTTTTTT…. If you have already read them, please let me explain why they should be read in this order so I can clarify any loose ends.

 First of all, to understand anything about my posts, you must minimally acknowledge that something such as informatics does exist.  Since the post above specifically deal with the pharmacy, posts 2-5 is the general order things would actually occur.  Post 2 and 3 are similar in the fact that this is where everything starts depending on what medication is needed (FYI-there is also a unit dosing machine for oral liquids that I have not discussed). It explains what unit dosing is and how it’s able to happen.  Post 4 enables you, the reader, to have a more visual understanding of why we unit dose in the hospital.  In post 4, I did not fully explain that the Pyxis provides patient specific information.  In post 5, I also did not fully explain the aspects of communication the pilot system allows.  The image below was illustrated on post 5, but unless you zoom in, you probably did not read it.

Hopefully you now see how posts 4 and 5 relate.  A lot of the communication that is delivered through the pilot system is due to the medication not being available in the Pyxis.  At HIPPE, like other hospital pharmacies, we’re still developing. Since the Pyxis system is relatively new and it’s currently being adjusted to better suit individual hospital sections, we are striving to reach the goal of storing 90% of the needed medications in the Pyxis.  Until this 90% occurs, the notifications sent in though the pilot program will have a high influx rate of out of Pyxis notifications.

I hope I clarified any confusion I may have caused, but to be quite frank, I’m no expert in the field of pharmacy OR informatics, and since I’m still learning myself,  I cannot post things in a more sensible order if I don’t know they exist.  Please take your time in continuing reading my blogs so we can learn about pharmacy informatics together!

Pyxis

Have you ever watched a show like Nurse Jackie?  If so, you probably noticed that after the pharmacist got fired, they replaced him with a machine that dispenses individual unit dose medications to the nurses.  At HIPPE, this machine is called a ‘Pyxis,’ but it may have other names at other hospitals depending on the company who makes it.  In all actuality, a Pyxis cannot replace a pharmacist!  There are other machines that hospitals use to decrease the amount of pharmacy staff, but these machines are not a Pyxis nor would they be able to replace all pharmacists. 

            If you have never worked in a hospital, you probably have no idea what a Pyxis does even though you have seen it in a television show.  A Pyxis enables nurses to have easy access to medications in a unit dose form for their patients.  It may sound as if the pharmacist is obsolete if their not giving the medication to the nurses, but they’re not! The Pyxis actually enables pharmacist to primarily be used for their clinical knowledge in medications.  The Pyxis will NOT let a nurse take a medication out if a pharmacist has not approved the use of it for that SPECIFIC patient.  If the pharmacist finds something wrong with the doctors’ prescription or the nurses’ refill order, they can reject the order.   This is where the pharmacist gets to use all their schooling.  Previously when a doctor or nurse called in a medication, the pharmacist would have to rush to verify that the medication itself was correct, check its specific use for the patient, and then either deliver it directly to the nurse/patient or find someone to do it for them.  With the Pyxis, technicians have already brought commonly used medications that the pharmacists have already verified to the different floors.  So now when a medication is called in, all the pharmacist has to do is make sure its clinical use is the most optimum for the patient.

("Pharmacy automation," 2005)

            This week I had one of the pharmacy staff members introduce me to the Pyxis.  I asked how they decided which medications to stock in the Pyxis would be the best choice, and I received a great answer!  Although the pharmacy can easily create statistics to see which medications are used the most based on their past history, the Pyxis itself creates charts/graphs to show which medications are specifically used at each station in the hospital (since each section specializes in different segments of health).  The women in charge informed me that their goal is to have roughly 90% of all medications used at each station to be available in the Pyxis at any given time. 

            If you ever walk through a hospital and see a funky looking grey cabinet with a computer monitor on top of it, STOP and take a good look at it!  Think about how large a pharmacy must be to store ALL medications needed for ALL patients to try to minimize out of stock complications.  Now realize that the small area the Pyxis is taking up is storing roughly 90% of the medication variety that patients use on that floor.

I am personally amazed at what this technology does, but there is just too much to say considering the fact that I have never had access to it myself.  To learn more on the Pyxis, feel free to visit anyone of the links below!

RxAutomation

Carefusion

Pyxis training power point

Pictures from:

Pharmacy automation. (2005, November 06). Retrieved from

        http://www.uihealthcare.com/pharmacy/RxAutomation.html

Nurse-to-Pharmacy Communication

***PILOT***

            As I was reading up on tweets one day, I found an interesting article that discussed how a lot nurses spend more time with documentation then with their patients.  At HIPPE, the pharmacy is trying to improve the communication and safety of nurse-to-pharmacy communication.  They are starting to use a program called ‘Pilot’ so nurses can easily order refills, call in ‘retimes,’ or for any other reason if the medication is currently active in the ‘Med Charting’ system.

           

            This communication technique increases patient safety enormously!  If a nurse were to call in an order, there is a potential for medical errors by miscommunication and misunderstanding.  Also, sometimes the pharmacy is too busy and the nurse is put on hold, which decreases the time the nurse can be helping another patient.  If a nurse uses the pilot program, all the patient information is already in the system!  All the nurse needs to do is say specifically why she is contacting the pharmacy.  After I became familiar with the system, I found that I could complete the order within 30-45 seconds without any effort at all.  Since I work in the pharmacy, I could also see the orders sent in this way.  After reviewing several orders, I realized that it was much easier to understand the nurses this way then over the phone.  Also, now there is a HARD COPY DOCUMENTATION of the nurses directly contacting the pharmacy, so incase there is someone at fault for a specific situation, there is no “he said, she said” subjectivity. 

            Currently, it is my responsibility to train nurses at HIPPE how to use this program.  A third of the nurses already knew how to use it, but did not understand the importance.  Another third of the nurses absolutely loved the program and said with great enthusiasm that they used it “ALL THE TIME!”  The other third had never heard of it, but once I showed it to them, they all seemed highly impressed.  Some of the older nurses did not want to here about new technology and put up a fit.  After showing them one by one, I got responses such as “that was easy.”  I just looked at them and smiled and said “sure was!”  This system is great for nurses, pharmacists, but most of all, the PATIENT!  The hospital is all about patient safety and this system shows everything that everybody currently knows about that individual patient in one program.

Linkage

My sister visited her pharmacy the other week to pick up medication X.  Several weeks earlier she had visited a different pharmacy (in the same chain) to pick up medication Y.  About a week after taking both medications at the same time she experienced major gastrointestinal symptoms. 

            Several weeks later she visited her doctor to discuss her general health and the progression of her disease states.  She talked about her stomach issue and was informed by her doctor that medication X and Y together are known to cause serious adverse drug reactions.  After the appointment she called me to complain about the fact that her pharmacy missed the drug interaction of the two medications together.  My first response to her was “did you use to different pharmacy locations for the medication?”  She paused for several seconds and shouted back “YES!” Then she farther complained about her situation.

            When you or I visit a pharmacy, they create a record of what medications we’ve bought from them, what allergies we have, and any other important medical information they should know that would pertain to our medication therapy.  Now, if you went to Publix pharmacy and then visited a different Publix pharmacy or another chain all together, they would not be able to tell very important missing information because each stores profile contained for an individual is usually based on only that specific one store (even if it is part of a major chain). The point I’m trying to get it is the fact that the systems are not linked.  This is why pharmacies encourage patients to only use theirs and try to entice patients with coupons for transferred/new prescriptions.

            Unlike other pharmacies, I am employed by a major retail corporation that is developing a way to link their stores profiles together to account for patients using their chain in multiple locations.  (I will call this chain pharmacy MFR) Right now, MFR has stores that are located in the southern region of Florida linked in this system.  When a sick patient decides to visit the MFR I work at only because it’s on the way home from their doctors’ office, which is a different MFR then they usually go to, their home stores profile will be linked with mine.  This means I can safely confirm that the patient will most likely have few (if any) drug interactions, allergies, or medical issues due to complications of the newly prescribed medication with older ones. 

Systems like the one MFR employs are FANTASTIC!  They help increase patient compliance and pharmacist awareness.  MFR helps to assess a problem that would not have been caught otherwise.  Before MFR started using this new program last year, they would have to do a central search to see if the patient went to another MFR in the area.  Although they could see the other medications when ACTIVELY looking for them (ex. doing a transfer), it doesn’t mean that they would catch the drug interaction.

Although MFR is a great application, since it is new, it faces a multitude of problems.  For instance, I live in Davie and have all my prescriptions here.  When I go back to Orlando for a refill or new Rx, they are not linked with the Davie MFR because only limited regions have started using this program.  Also, if the program crashes from the main source, then all of the stores that are linked with it will stop working.  Since it is a relatively new program, their may be other problems that will arrive that have not occurred yet.

Although MFR is one of the first entering this new error of ‘linkage,’ just imagine if all pharmacies were linked together through a national database, and not just their own chains.  I know this sounds a lot like “big brother,” but how awesome would it be to know that the information you provided one pharmacy was linked with all others incase you ever need to use them (but would of course still abide by HIPPA).  This is my dream, and I truly believe this could easily become reality.

DOSEEDGE

I started out my day at HIPPE walking around the pharmacy asking anyone if they needed any help.  After several minutes, I gave up and saw one of the technicians using a machine I had never seen before.  By looking over his shoulder, I saw he was taking pictures of vials and IV solution bags.  Once he saw that I was interested he started to explain what he was doing.

Several months ago HIPPE received a machine called DOSEEDGE (Pharmacy Workflow Manager).  This machine enables technicians to take pictures of IV room medications and have the pharmacist approve them through a computer system instead of manually checking each one.  The technician is required to scan the medication and then take a picture of both sides of the vial and IV solution bag so the pharmacist can see all of the information; such as doses, names, and expiration dates.  When the pharmacist sees an error or cannot view what the picture is, he can choose that individual medication to be sent back because it allows tractability because it stores electronic records and provides audits of what was done.

You may be thinking that his makes a pharmacist lazy because he/she would only have to see the medication on a computer instead of in person.  Yes this technology does allow the pharmacist to stay comfortable in their office, but this program has many benefits!  For instance, DOSEEDGE helps eliminates medication errors through integrated drug verification and by providing dose and dilution calculations.  Also, if there is a need for an IV medication approval that is needed really fast, a pharmacist can verify it from anywhere as long as he/she is connected to the intranet. 

Since this is a new machine at HIPPE, I had to ask the obvious question “have there been any problems with it?”  Although the technician did say yes, the problems he described seemed minuscule.  He reported problems such as picture imaging and generic malfunctions of the use of the machine itself (ex. freezing).  From what I have read about this program, it seems to be safe, cost effective, and an efficient addition to pharmacy informatics. 

DOSEEDGE:

STEP 1-Use the touch screen to prepare the dose and the label will print

STEP 2-Scan the product (it will alert you if it is wrong)

STEP 3-Scan the label and attach it to the product

STEP 4-Draw up each ingredient

STEP 5-Take a picture of the vial and syringe

STEP 6-Make sure the computer has a clear image

STEP 7-Inject the ingredients into the final dose

STEP 8-Take an image of the final dose and scan the label again to finish

Doseedge. (2010). Retrieved from http://www.baxa.com/doseedge/

FACEBOOK: Social or Professional...OR Can it be Both?

The other day I was working at HIPPE with the slowest computer EVER!!! This computer would only let me type a single word ever five minutes.  So I decided to take out my iPod and visit the infamous Facebook.  After several minutes of catching up on the world I once knew before school started, I remembered a news report I had heard several weeks ago.  The news discussed how doctors were using Facebook to connect with patients.  You may be thinking how great this is, doctors and patients connecting on a personal level… But is this great? Does it abide by HIPPA? And is anyone documenting what they’re saying to each other back and forth????  These are just some of my questions.

Personally, I have learned NOT to use a social network to connect with people in my profession who really aren’t my friends because it can backfire.   When is a patient considered a friend and no longer a client?  Doctors are not only using Facebook as a way to connect on a more personal level with their patients, but they’re also using it to distribute medical information.  Personally, I find that splendid that a doctor would take his/her time to update patients on information.  Some doctors take distribution of general medical information a step farther.  By this, I mean that some doctors actually hold Q & A’s on their profile and talk about common questions their patients ask about during visits.  There is a thin boundary between distributing general medical information and personal information. 

What were to happen if a doctor saw a female patient with herpes, and right after she left his office he goes on his Facebook profile and posts a status update about reminding people to be cautious of sexually transmitted infections (STIs).  As this women walks out of his office, another patient in the waiting room sees the update and automatically believes Dr. Social is talking about her.  Using Facebook in a professional matter may not be the best idea for any career.  Medical professionals need to be very cautious on what they say about medical cases because it is easy to slip and violate HIPPA. 

Although Facebook can be used as a professional network, it is still looked at as a social network.  Ironically, socializing about medical issues can help deliver a cure even without a doctor.  For instance, last year during finals I was sitting in my room studying while going crazy and itching EVERYWHERE!  I thought stress was tarring me apart as I broke out into the itchiest rash I have ever had.  As I procrastinated, I went on my Facebook account and typed something along the lines “I CAN’T STOP ITCHING” on my profile.  This may not have been the smartest idea after viewing many of the horrific comments I received from ‘friends.’  BUT, one comment from a close friend said “me two!”  It was then we both realized why we were both ridiculously itchy.  It had nothing at all to do with stress.  The past week, it was Thanksgiving, so we decided to give ‘thanks’ by help cleaning out a park.  The park decided to give ‘thanks’ back by giving us the gift of allergic dermatitis from the plants we touched.  We both ended up receiving a steroidal cream and an antihistamine to take care of the problem.  If I had not posted this status on Facebook, the problem would have persisted longer because the doctor I visited proscribed me a medication for scabies….AND IT WAS NOTHING LIKE SCABIES!!!

In the end, it is really up to the patient whether they are ‘ok’ with their personal information being shared.  Doctors need to be cautious what they post and need to continue to abide by professional regulations.  Just remember, if you think you may be revealing too much personal information, you probably are, SO DON’T POST IT!

ISMP

Novolin/Novolog…Ephedrine/Epinephrine…Zyprexa/Zyrtec

How often do you read something and assume a word is something else?

            This may not happen to you, but it happens to me all of the time!  For example, on many tests, I will read correct instead of incorrect.  Doing this really upsets me because I miss the answer unless I notice it when I go through the test a second time.  I now try to CIRCLE those words that I easily misread when I catch them so I know to look back and see if what I read was correct.

            In the pharmacy, everyday is a test. If you and/or I fail to recognize something as minute as a one or two letter word differences, it could mean the end in a patients life.  Since so many medication names sound and/or look alike, it is beyond easy to grab the wrong one (especially when working at a fast paced).  Sadly, mistakes like this happen all the time and it then becomes the pharmacist job to do that double checking. 

The Institute for Safe Medication Practice (ISMP) tries to enable a safer practice environment for pharmacies.  One of the things they try to implement is proper labeling of medications of the look/sound-alike medications by using TALL man lettering (aka capital letters where the names differ).  Although there are tons of people who are lucky enough to rarely misread information, for the ones who are (like myself), these guidelines make working in the pharmacy so much safer.  It is up to pharmacy to implement the use of those labels that follow the guidelines.  This was my job yesterday.  I was in charge of changing all of the labels that stored oral medication to have matching labels that were easy to read based on ISMP guidelines. 

After a half an hour of typing the labels based off the old ones, I realized there were a lot of spelling errors and brand/generic name was missing.  For some of these medications that I already typed, I started pulling the bottles out of the bins to find the correct information (which not all of them had).  All of the sudden ‘POOF’ I had an epiphany.  I reached into my white coat and pulled out my iPod.  I started plugging in different medications in Epocrates and getting all of the answers I wanted.  (I could view all the brand/generic names, doses, use etc.) With the help of ISMP and Epocrates, I was able to contribute to the safe medical distribution of HIPPE.  Currently, my iPod has come in use for fun, home work, pharmacy knowledge, and now making a safer environment for patients.  It’s crazy to think that a tool that can do all of this fits right into my pocket.  Today’s use of technology in medication will save tomorrow’s patient.