Meaningful Use: Your prescription shouldn't have to look like this

I spent a year studying medication safety at the Institute for Safe Medication Practices, the nation's only patient safety organization devoted solely to medication error prevention and safe medication use. So I'm always on the lookout for ways to help others see what I learned to see.

My friend had a friend-of-a-friend deliver a load of pine straw to her home the other day. The delivery man left an invoice, and my friend asked me to interpret the name of the company so that she could write a check.


Take a look and see what you think.

I guessed "Chevrolet" (even though it seemed like a weird name for a handyman service.) My friend frowned. She's a middle-school math teacher, and she's detailed-oriented. "Leave it blank," I suggested, "and mail it. Mr. Pinestraw can fill it in." More frowning. (This suggestion was clearly not welcomed by my friend, one of the most reliable people I know, someone who dots her i's and crosses her t's and is not in the habit of leaving things blank.)

Several days later, my friend mentions she's going to drop the check for Mr. Pinestraw off, having finally tracked him down via telephone and clarified the name. "Cherokee!" she says triumphantly!

To average Walmart shoppers like myself, health policy and IT discussions about how $20 billion dollars in economic stimulus funds are going to be put to meaningful use sound a lot like Charlie Brown's teacher: "Waoao waoaoa waoaoa wah woaoao."

So, let me draw on the med safety expertise and call out a few suggestions for how I think monies spent for meaningful health IT should be visible to healthcare consumers:

1. People who prescribe medications should use a system more sophisticated than the pine straw delivery guy's to communicate high-stakes drug information. 1,400 commonly prescribed drugs have names that look-alike or sound-alike. People can, and do, die when drug names are confused with one another.

2. Pharmacies should be able to receive prescription data in a format that does not require the tenacity of a middle-school math teacher on summer holiday to decipher.

3. Your electronic medication history--housed with your physicians, pharmacy, and any consumer portal you choose--should move seamlessly into hospital data repositories and be accessible, with your consent, during planned and emergent encounters.

Jon and Kate: I think I'll medicate!

Call me silly, but I'm always surprised when highly predictable events happen. Take the high-profile dissolution of Jon and Kate Gosselin's marriage.

Under circumstances that can best be described as childbearing Yahtzee, a young couple in rural Pennsylvania manage to add six-of-a-kind to the deuce they rolled in the first round of play. Shortly thereafter, they score a reality TV series, adding producers, cameramen, photographers, hired help, speaking engagements, investment portfolios, and book tours to the primary task of raising eight humans, six of whom--unfortunately and largely without precedent--share the same developmental stage.

She thrives, leaving the stay-at-home-mom-who-happens-to-drive-a-church-bus image behind and morphing into someone who might be credibly cast on "Real Housewives of Punxsutawney." He begins to resemble Jim Carey in "The Truman Show." The marriage crumbles. Who knew?

Marriage in the U.S. doesn't have great odds to begin with, and marriages with high-order multiples have higher failure rates than others. But like Captain Renault in Casablanca, we're shocked, shocked to find that gambling is going on in here!

The denouement of Jon and Kate has left me thinking about medication use, a topic that could reasonably be expected to arise in an upcoming episode. So, in the short window of clarity that followed the "ah-ha" moment when I learned Jon and Kate ain't great, I jotted down eight things about medication safety that you, too, probably knew all along. (Apparently, we should be shocked, shocked to find that gambling has been going on here!)

1. If you routinely identify patients using 2 distinct identifiers and engage them in the care that's about to occur, you're less likely to give a patient the wrong medicine, conduct the wrong test, or perform the wrong surgery.

2. If you make drug information available to clinicians on the front line (preferably in a mode that's as easy-to-use as an iPhone, not a dogged-eared text from an earlier century), the clinician administering drugs will be able to become familiar with, and actually double check, unfamiliar drugs and doses before administering them.

3. If you say "fifty" (without saying "five-zero") over the telephone, you're likely to be heard to say "fifteen." "I'll be there in 15 (or 50?) minutes" is not as much of a problem as, "Give her 15 (or 50?) units of insulin." Break multiple digit numbers into their simplest form, say and spell drug names, and read back and verify high-stakes information that's transmitted verbally.

4. 1400 commonly used drugs look like or sound like another one. These similarities regularly cause competent people to select an unintended drug from a computerized pick-list or mis-hear a drug as its sound-alike cousin. If you include the purpose for the drug on all orders or written prescriptions, this information allows another knowledgeable professional (like a pharmacist or nurse) to detect and derail a look-alike, sound-alike (LASA) error since few members of LASA drug name pairs are used for the same purpose.

5. If balsamic vinegar and olive oil come in similar containers, it's easy to kill a quesadilla. How drugs are stored at work matters, too.

6. If something can be attached to something else, someone will attach it. Good for tinker toys, Legos, and jigsaw puzzles. Bad for oral medications in parenteral syringes and pressurized B/P tubing connections that are compatible with IV lines. If you can't put diesel fuel into your gas tank by mistake, why don't we have similar safeguards in place at work?

7. If the lighting is bad in a restaurant, you have trouble reading the menu. If the lighting is bad over automated drug dispensing cabinets, your front line is going to have trouble reading the labels of the drugs they remove from them.

8. The average age of a nurse is around 50 years old. Most drugs that are given today were boiling in a cauldron somewhere when we took our boards. If you define how risks associated with high alert medications and LASA drugs are managed in individual care settings within your organization and teach these strategies to nurses (and others who handle drugs), you will prevent mistakes that have been made elsewhere from occurring where you work.

I hope you find these 8 to celebrate, agitate, and advocate, eight things that will help you take care when you medicate!

Be Where You Are

I had planned to write about chipper-shredder mishaps today, sharing how a random call to jury duty introduced me to the discipline of Human Factors engineering and changed what I believe about people, lawn & garden equipment, and healthcare delivery systems.

Principles from human factors and cognitive psychology are important because they help to determine a rank order for risk reduction strategies. This helps clinicians identify the best strategies for preventing error, and helps administrators make provisions for endorsing, and funding, the risk-reduction strategies most likely to work. These are interesting things to talk about.

But sometimes, you've just have to be where you are. Today, I'm providing hospice care to our family's 12-year-old yellow Labrador retriever, Daisy. I'm trying to figure out the best plan of care and reviewing her recently acquired medication list in hopes of finding some hopeful explanation for her marked downturn. (Also cleaning up big messes, running the space heater, and trying to maintain a minimal-stim environment for Daisy, who prefers to stay curled up near, and occasionally on, my feet.)

We all regress under stress, I guess, and Daisy's working hard to stay connected. But when I'm "feeling" more than I care to, I become hyper-analytical, hoping to move back to the "thinking" place where I'm more comfortable. So I'll share a few nuggets from my unwelcome journey:

1. You can get medications for your pet at your local pharmacy. In the past, the medications our pets have needed all came from the vet's office, but when your pet moves into a high-octane plan of care, it turns out you can go to the same gas station where you get yourself fueled up. (At least you can do this in the state where I live.)

2. Pet medications are another variable in the look-alike packaging maze. Since this is a process-oriented blog, I'll invite you to look at the photo of Daisy's meds again. Notice how the one that came from the vet's office (on the right) has the distinctive pet silhouettes? I think this helps prevent distracted, stressed-out, and yes, tearful, pet owners from inadvertently taking their pet's medicine. The prescription on the left-hand side came from the real pharmacy, where my family gets our prescriptions filled. You can see that I flagged it to help me see--from a distance and maybe without my glasses on--that these pills belong to the dog. It would be better if all meds dispensed for canine use were placed in bottles like the one on the right.

3. Separate pets' medications from the family's stash. Maybe you are inherently less error-prone than I am, but the consequences of a mix-up could be huge. Separating look-alike containers is a stronger risk reduction strategy than simply trying to "be more careful."

Especially when you're crying.

Where's Waldo? Finding Reliability in Surprising Places

Last Friday, I talked about look-alike, sound-alike (LASA) drug names, throwing out for discussion just one of the system-level risk points that predispose people to err. Remember Waldo, the popular figure in the striped shirt kids have fun trying to find? I think of risk points as "Waldos" because they're often significant stumbling blocks, features hidden in plain sight that undermine the ability to deliver intended care. Without specific measures that make Waldos visible in healthcare, they frequently derail our good intentions.

(Oh, and if I’ve sparked your interest in LASA-related drug errors, you can click here to access a graphics-rich, user-friendly, CE-granting tutorial about this problem. It offers a more complete discussion of LASA problems and prevention strategies. Disclosure alert: I'm a co-author of the piece, but I don’t receive any tangible benefit by sending you over to Medscape to access it.)

But today, I want to circle back to common beliefs about intention and individual performance, making comment about what's known about reliable performance.

If you're like me, you probably get a chuckle when signs like these hit your electronic in-box.

(The "Darwin Awards" are another funny cousin in this family of pass-along e-mails.) These "just do it" calls-to-action are helpful for instilling personal accountability when performance is not overly dependent on a system, like it is with, say, teenagers and curfews.

But imagine you are boarding a commerical airliner, and you see a warning posted in the cockpit that says, "This machine has no brains. Use your own." Are you staying on-board? It probably doesn't matter, because the crew isn't likely to!

The experience and competencies your flight crew and air traffic controllers bring to work are not considered sufficient to get a plane off of the ground if the plane's brains (think: radar, auto-pilot, computer) are on the blink. I know this from experience. Last year, I flew between Atlanta and Philadelphia weekly, a routine that was largely uneventful. But I vividly recall one flight that required a return to the gate, de-planing, and re-loading onto another aircraft, events that transpired when the captain nixed take-off because the mechanics could not explain to his satisfaction why a control panel light was behaving in an atypical fashion.

Aviation professionals understand that safety is a function of reliability, a term Wikipedia helpfully explains as the ability to deliver stable, predictable results under ordinary circumstances as well as when hostile or unexpected events arise. Aviation is highly procedure-oriented, and it's likely that the ability of individuals to perform in extraordinary circumstances, like when a plane lands on the Hudson, lies in the strength of the systems that support routine function. The aviation industry routinely adopts tools and technologies that enhance the considerable abilities of individuals to perform in a reliable fashion, and they share "Waldos" across the industry whenever the safety-threatening striped shirts are identified.

Human beings, healthcare's most significant output, are far more complex than airplanes. But this fact should not dissuade us from adapting reliability-promoting processes used elsewhere. Deviation from a standard flight plan (or plan of care) for cause--that is, for reasons that enhance benefit to individual flyers (or patients)--make sense only when deviation is not the norm.

I hope you'll stay safe, come back soon, and fly only in friendly skies!

LASA: It's Not Just Another Bad Abbreviation

I'm talking about errors associated with look-alike, sound-alike (LASA) drug names today because LASA problems offer concrete examples of risk points that dog clinicians involved in the medication use system. (For purposes of this discussion, my quick-and-dirty working definition of a risk point is "any underlying factor that predisposes to error.")

In the last post, I referred to new research confirming something you probably already know: healthcare professionals struggle with reporting mistakes, and we struggle with the fact that we are fallible when we're involved in errors. When people believe that “bad people” or “good people having a bad day” are individually responsible for most medical errors, it’s easy to see why reporting error and reconciling feelings of personal responsibility become burdensome. But reporting and reconciling become easier when you look for solutions that improve the nature of the process, not the nature of the people. Face it, we’re all going to have a bad day once in awhile, and, unfortunately, not all people are good.

(I recently spent a year as the Safe Medication Management fellow at the Institute for Safe Medication Practices. But, as you can read in my last post, I was tripped up by look-alike packaging of hand sanitizer and hand soap a few weeks back, proving yet again that “knowledge” does not trump “process.”)

Human error is typically a by-product of the systems we practice in, and with LASA errors, it’s hard to miss the risk points. The category of LASA-related errors exists because, frankly, drug names are often similar to one another. It's easy to see how words and phrases like "oxycodone and oxycontin" and "Novolog Mix 70/30 and Novolin 70/30" could be mixed up. Similarities like these regularly give rise to confusion, and yes, error. We see look-alike, sound-alike word confusion in other settings all the time: if you haven't seen "your" erroneously substituted for "you're" recently, you're reading better things than I am! But when word mix-ups have the potential to give rise to medication errors, stronger processes that guard against selecting the wrong one need to be in place.

Next time, I'll share data and some easy-to-access resources for preventing LASA errors. Maybe you have an example of a look-alike or sound-alike error to share? (If you do, tell your story in the “comments,” omitting identifying information. On Florence dot com we neither offer medical advice nor violate HIPAA regulations.)

So, good people, stay safe and come back soon!