A Blue Christmas

The message inside the card reads, "Wishing you Christmas peace."

Some things just don't make sense. 

Elvis-as-messiah is one of them. And why a pharmacist will spend Christmas behind bars this year for an on-the-job error is another.

You can read more about Eric Cropp and the circumstances behind the tragic death of a toddler here.

Eric's address in the Cuyahoga County, Ohio jail appears at the bottom of the linked article. I'll be sending him one of the Elvis Christmas cards. There are 17 others in the box. I'll be happy to send one on your behalf, too.

Don't throw a skater under the Zamboni when you're already on thin ice

I spent a few days last week with my friend and mentor, Mike Cohen, the President of the Institute for Safe Medication Practices. Although Mike has a goodly number of titles and highly recognizable accomplishments (like being named a MacArthur fellow in 2005), you might enjoy spending time with him for the same reason I do: He's a mensch.

When Mike worked as a clinical pharmacist in a hospital pharmacy over three decades ago, he observed how frequently flaws in the system used to deliver medications set professionals up for failure. Systems engineers use terms like "single fault failures" and "opportunities for recovery" when they design work processes that reliably produce an intended outcome. But it's easier to think about these concepts using things we know from our own experiences.

Let's say we send a group of ice skaters onto a frozen pond. Some skaters in the group are Olympians, some grew up on a lake in Moose Jaw, Saskatchewan, and some are promising beginners. Everyone who skates on your pond knows how to lace up and is able to remain vertical while on the ice. They look good and on days when the ice is frozen solid, all skaters skate safely.

But your ice is not uniform. When the temperature climbs, the ice becomes thin. Dangerous spots are not marked. The skaters from Moose Jaw are better able to spot unsafe ice. They stay off or take action to avoid the risky patches. Statistically, Moose Jaw natives fall through less often than the Olympians and the beginners. But at times, even the Moose Jaw skaters go through the ice.

Variability is the enemy of people interested in engineering safety. Variable conditions make it tougher for beginners to navigate a high stakes process safely. When one of your lighter weight Olympians glides over a thin spot without falling through, beginners erroneously believe the ice is safer than it really is. Variability will trip up seasoned people, too. And when no one has gone through for awhile, it's easy to forget how important it is to mark the weak spots and have a means to pull someone out when the ice cracks.

The medication use system is built on thin ice. It was in the 1970's when Mike Cohen first began imploring healthcare providers to look beyond the characteristics of the last skater who crashed through and it remains thin today.

Here's the evidence: Since 2004, Pennsylvania has required healthcare facilities to report serious adverse, unintended medical events and near-misses to the Pennsylvania Patient Safety Reporting System (PA-PSRS). This reporting occurs irrespective of whether patient harm occurs. Last month, PA-PSRS logged its one millionth report. Over 25% of these events involve medications.

You should infer that similar data could be culled from the state where you live. Remember that, like the people in Pennsylvania, you'll have beginners, Olympians, and Moose Jaw natives on your pond. Ask what measures are in place to ensure the ice is being shored up and the thin spots marked. And you should be interested in ice conditions whether you are a patient or a professional.

In hospitals, things that shore up medication safety fall into broad categories that are objective and observable. In fact, ISMP makes a series of comprehensive medication safety self-assessment tools available for free download on their website. Using these tools, organizations can measure their progress in making medication delivery safer over time.

You should be interested in what happens to skaters who fall, too. At about the same time that Pennsylvania passed the one million mark after five years of error reporting, the citizens of Ohio sent a pharmacist to jail for an inadvertent on-the-job error, one that led to the tragic death of a toddler.

Mike Cohen has published a detailed piece An Injustice Has Been Done that explains how thin the ice in the Ohio case was. It's an impassioned plea about the dangers of punishing people whose primary fault arises from being a fallible human.

In the past five years, Pennsylvania has had 1,000,0000 events reported, each an opportunity to identify a variable that affects the quality of the ice and improve it before harm occurs. (Only 4% of the Pennsylvania reports involve patient harm.) If skaters who stumble know they will be pushed the rest of the way down, who will make a choice to share details about what undermined their performance?

And down the road, when your team can no longer recruit Olympians and Moose Jaw natives, you'll be crossing increasingly thin ice. You won't need particularly sharp blades to push the beginners under.

Keeping the Rx train on track

The medication use system is hooked together, kind of like cars on a train. And the cars would be labeled:

• prescribing


• dispensing


• administering


• monitoring
  

Seminal medication error literature suggests that errors originating in the prescribing car account for about 40% of all errors and represent 28% of harm-causing errors. Nearly 1/2 of errors that arise during prescribing are picked up before they reach a consumer, mostly because the cars that follow contain check points and feedback loops to detect and right the error. But this means that a substantial number of errors remain undetected, errors that potentially harm patients, or in some way derail the intended plan of care.

Computerized Prescriber Order Entry (CPOE) holds the promise of increasing the reliability of activities that occur in the prescribing car. Automation ensures that patient allergies, duplication of therapy, and potential drug interactions are considered during each prescribing cycle in a way that reliance on even the most diligent human cannot.

When CPOE's best potential is realized, active errors originating in the prescribing phase will be reduced. So will passive errors that occur when high-stakes drug information is not transmitted across the continuum of care and is not readily available to treating clinicians.

Depending on the outcome of national discussions surrounding the use, the meaningful use, of 20 billion health IT-earmarked dollars, the average Walmart shopper can expect to see universal e-prescribing, ummm, soon. Until e-prescribing is fully implemented, people in the U.S. will live (or not, as the case may be) with hybrid systems.

Here's what I tell consumers to do to decrease the chance that a prescribing error will make it home:

1. When you receive a prescription for a medicine, it should be legible. Ideally, this means that the prescription is sent to your pharmacy electronically and you receive a printed copy. If it's not an electronic system, and you have to hand-carry a prescription to the pharmacy, it should be legible.

A "legible" handwritten copy of a prescription is one you can read. (It's not necessary for you to understand every word, term, or symbol, but you should be able to see and distinguish each word and number clearly). Pharmacists and pharmacy technicians have a lot of specialized knowledge, especially about drug names and products that are currently on the market. But they don't receive CIA-level training to decode poor penmanship. Making "an educated guess" is not what they're supposed to do nor is it what you want them to do. (Think of your prescription like the directions a pilot receives. Would you be willing to taxi to a runway knowing the pilot received directions he couldn't read clearly?)

2. Know what's included on your prescription and why it's important:

• who is prescribing it


• who it is being prescribed for


• the date of birth of the patient (or another identifier in addition to the patient's name)


• known drug & food allergies of the patient


• the name of the drug


• the dose of the drug


• how many pills or how much liquid should be taken in order to achieve the desired dose


• how often the drug should be taken (usually expressed in "times per day" or "times per week")


• the quantity the prescriber is authorizing (how many pills or how much liquid you will receive)


• the number of refills you may receive


• the reason for taking the drug

When your prescriber (the doctor, nurse practitioner, or PA) includes the reason for the drug on the prescription, it provides another layer of information (a redundancy) to help ensure the correct drug is dispensed. 1,400 commonly prescribed drugs appear on lists of regularly confused drugs. Few of these drugs are used for the same purpose. This means that in the event your prescriber doesn't write clearly or the drug name is misread in the pharmacy, the pharmacist performing the final check has another "match point" to help detect an error. In a high-stakes, high-consequence process like medication use, you want lots of checks and double checks. (Medicine may look like candy, but it's not.)

3. Finally, when you pick up a prescription, open the bottle and look at the pills. When you're asked to sign for a prescription, you're likely signing something that says you have no questions and don't require/request additional face time with the pharmacist. Everyone has a least question when picking up a medication, and the question is this: "Did I get the right drug?" Look at the label, or ask that it be read to you. Is this the medicine you expected to get? Is the dose correct? If the name or appearance is different, the pharmacist can explain why (perhaps a generic brand was substituted) or an error that's been set in motion can be detected before you take the medicine home.

Perhaps the most worrisome thing about transitioning to e-prescribing is IT's guiding principle: "garbage in, garbage out." Take a look at this old-fashioned prescription, written just a few months ago for a member of my family.

Although the elements recommended for inclusion in any prescription are easy to list (see above), they are not included on the pre-printed prescription form used by the group of prescribers, a format used by the majority of prescribers in my community. (I blanked out most identifying info but left the "Children's" portion intact to remind myself--and you--that children are among those most at-risk-for-medication-errors and most likely to suffer harm when an error occurs.)

This process is garbage, folks. Just ask the IT person who is trying to automate it.

Where's the engineer of this train wreck?

Every year in the U.S., 1.5 million people are harmed by medication errors, events that add billions of dollars to the healthcare economy. The medication use system we rely on is a lot like a train sent down the tracks without an engineer. Not only was it not "engineered" in the first place, few people on the train understand everything necessary to ensure its safe operation. Worse, most people on board wrongly assume that someone is, indeed, in charge and sit back, assuming they are free to relax and enjoy the ride.

Maximizing the safety of medication use is no short journey. You start with a complex system that involves licensed individuals, crosses the disciplines of medicine, pharmacy, and nursing, is highly regulated, has deep-pocket special interest groups, and requires a high degree of cooperation and communication amongst professionals and consumers. Oh, and to cement your joy, if you include the word "medication" in a sentence, you've just catapulted the instructions out of the range of the fifth grade reading level that health materials are supposed to be written at. ("Medicine," yes. "Medication," no.)

Medications have to be prescribed (or for OTCs, selected by consumers) dispensed, administered, and, in some way, shape, or form, monitored for effectiveness. For warfarin, the rat poison that mitigates inappropriate blood clotting, monitoring involves serial tests run on blood samples. At the other end of the spectrum are birth control pills, where monthly periods suffice. (Sadly, variability is not the friend of reliability.)

Systems engineers speak of "failure points," predictable places where errors are likely to occur. For example, not knowing that a patient takes warfarin when he or she presents for treatment of another condition is a known failure point that can be predicted to result in medication-related harm.

"Failure finding tasks," "performance shaping factors," and "exposure rates," are engineering concepts that rarely make their way into curricula used to prepare healthcare professionals. Yet when it comes to getting desired health outcomes what healthcare professionals know about how a system works may be as important as knowing how a person's system works.

Systems engineers also learn to design work processes to achieve three distinct safety-sensitive outcomes:

1. prevent errors (operative words: barriers, constraints)


2. discover errors set in motion before they cause harm (operative words: redundancy, "failure finding" tasks)


3. mitigate the potential for errors to cause harm (operative words/concepts: recovery, rescue)

There's a host of things that can be done to improve safety when medications are used. But the first step (and remember, this is always the first step) is to recognize that we--all of us--have a problem. If you prescribe, dispense, administer, or take medications, you have a problem: you're riding in a runaway train.

The good news is that the language of systems engineering can be learned, and concepts adopted and adapted to retrofit the medication use system. And you have a role, no matter where you're coming from. I'm going to begin an occasional series, describing specific actions and activities that can be used to strengthen the system. You'll find these posts are indexed with the label "engineering." All aboard? I hope you'll come back soon!

Fishing in a well-stocked pond

Florence has a sister, a new blog on the Medscape site called, "On Your Meds: Straight Talk about Medication Safety." I hope you'll take a look, and bookmark the site because On Your Meds is going to host a running commentary on specific strategies for reducing medication errors.

The current post is about high-alert medications, those with a heightened risk for causing harm if used in error. Insulin, chemotherapy, narcotics, drugs with weird dosing schedules, drugs with impossibly narrow therapeutic indices, drugs that result in closure of life-sustaining orifices if halted by mistake..... Let's just say that the drugs on ISMP's High-Alert list have earned their place.

I spent a year studying medication error prevention with ISMP, the nation's foremost experts on the subject. So I know more than the average bird, and often more than I wish I did, about medication errors. But you probably do, too: A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer.

People often wonder where I get the stories I use to illustrate key facts about med safety. Med errors can arise anywhere in the medication use process, a complex system (run by human beings) that includes: prescribing; dispensing; administering; and monitoring the effects of drugs.

Now consider that in a given week, an average of 82% of adults in the U.S. are taking at least one medication (prescription or nonprescription drug, vitamin/mineral, herbal/natural supplement); 29% are taking five or more. (These stats provide a snapshot of adults in community settings and exclude medications administered to people in hospitals and extended care facilities.) At this point, the stories find me. Or as Larry the Cable Guy might say, "You're fishin' in a well-stocked pond, sister."

Last week, I'm in the locker room at the YMCA, sharing a little more personal space than I'd rather. I've just finished cycling, and it looks like the Y member closest to me is preparing for "Twinges," the water class for people with joint disorders. She's chatting with a friend, and putting her clothes in a locker. The next thing I know, a bunch of pills, maybe 12, have spewed from the pocket of her balled-up Khaki pants. Some hit the bench, some the floor, and a few land in my gym bag. I help her retrieve them, phrases like "drug storage" and "mindfulness" flashing in my brain. She scoops up the last visible ones, examines her catch, re-pockets them, and says to her friend, "Good, I got the yellow one. We can still go to lunch."

I'm working on a project about insulin pens, visiting the manufacturers' Internet homepages and checking out the patient education materials available there. I notice images on a manufacturer's site where hip-looking teens are depicted using their insulin pens as hair accessories. Phrases like "drug storage" and "mindfulness" flash in my brain.

ISMP shares an error analysis in which a patient being treated for angina in a busy Emergency Department receives IV saline instead of IV nitroglycerin. The commonly used nitroglycerin is seated next to a similarly-appearing, but obsolete, glass bottle of 0.9% sodium chloride. The key elements? "Drug storage" and "mindfulness."

Across the continuum, themes repeat. I'll be reflecting more about them here at Florence dot com and at On Your Meds. In the meantime, it may be worth thinking about the utility of high-level risk-reduction tools. Should professionals use the same strategies to manage medication risks that senior citizens at the YMCA do?