I’ve been thinking about how the work we do today may impact the world we live in tomorrow.

Mark,

You have hit the nail right on the head in describing this problem.

The fact is that the majority of hospital pharmacies are making IV admixtures the same way that were over 45 years ago when I was a pharmacy intern working in a laminar air flow hood at St. Joseph Mercy Hospital in Ann Arbor, Michigan. It was one of the first hospitals in the US to implement a hospital-wide, pharmacy-based IV admixture service.

Let me correct that, a couple of things have changed, but not necessarily good things:

(1) Pharmacy technicians have replaced pharmacists and pharmacy interns preparing IV admixtures even though we have NO NATIONAL STANDARDS for the education and training of pharmacy technicians. Not only should we have national standards for all pharmacy technicians, but we should also have specialty certification for pharmacy technicians who are involved in the IV admixture process.

(2) We now have environmental standards for the pharmacy IV rooms (i.e., USP797) that mirror the GMP requirements for a parenteral pharmaceutical manufacturer, even though there was little anecdotal or scientific evidence that hospital pharmacies who were following pre-USP797 ASHP standards represented any significant risk. Granted, pharmacy prepared IV admixtures are probably cleaner than ever before, but has there been any decrease in infections secondary to pharmacy-prepared IV admixtures? For sure, we have made the Pharmacy IV preparation area more complex and that is usually not a good thing.

(3) Pharmacist rarely work inside the IV clean room. This appears to be a consequence of USP797. Pharmacists no longer directly supervise and check the work of pharmacy technicians. The hassle of garbing and un-garbing to move in and out of the IV Room is viewed as inefficient, leaving pharmacists to check the work of technicians after the fact, outside of the IV clean room.
Several years ago, technology was introduced in an attempt to eliminate preparation-related medication errors and to facilitate the remote checking of IV room pharmacy technicians. This technology actually has two components: (1) the barcode checking of the IV admixture ingredients (i.e., patient label, IV bag, medication vials) and (2) photographic images of the various stages of technician work in the IV hood to document what a technician has done and provide a basis for the pharmacist to check the work after the fact. Other vendors have created gravimetric capabilities to help determine if the correct volume of IV additives were added to the final IV admixture.

Too often, because of the additional complexity of introducing this imaging and/or gravimetric technology into the IV room workflow, the use of these technologies is limited to only high-risk IV admixture preparation. The fact is that even lower risk IV admixtures can have fatal outcomes, as evidenced by the lethal error that recently occurred in Bend, Oregon, where a neuromuscular blocking drug (rocuronium) was substituted for a fosphenytoin in a routine IV admixture. Consequently, all IV admixtures should be checked using barcode scanning technology during the medication preparation process (BCMP, bar code medication preparation), similar to how this technology is used at the time of medication administration by the nurse (BCMA, bar code medication administration).

Even though we have many new imaging/gravimetric technologies available for use in the Pharmacy IV room, we should start with the basics. All pharmacy-prepared IV admixtures should be checked utilizing barcode scanning (BCMP) regardless of whether other forms of “process-checking” technology (i.e., imaging and/or gravimetrics) are used. For many years, a hospital with their own pharmacy information system (i.e., Brigham & Women’s Hospital) used barcode scanning in the pharmacy IV room. Fortunately, a couple EHR vendors (e.g., Epic and MEDITECH) introduced BCMP technology for use in the IV room several years ago and two other leading vendors (e.g., Cerner and Allscripts) will have this technology by the end of the year. Likewise, there are other standalone BCMP solutions that could be used.

The bottom line is that ALL hospitals can begin NOW to utilize barcode scanning in the IV room for the preparation of ALL IV admixtures, regardless of whether they implement more advanced (and more complicated) “process checking” automation (i.e., imaging and/or gravimetric technology). This will allow hospitals to prevent the most serious “wrong drug, wrong patient” errors that can occur when barcode scanning technology is not used. Once BCMP is implemented, hospital pharmacies should then focus on how to optimize the use of the newer “process checking” automation technologies. Hospital gift shops have used barcode scanning for years. The time has come for patients to benefit from barcode scanning in the IV room…!!!