Device Improves High-Risk Medication Safety
Posted on: Friday, 11 January 2008, 11:15 CST
A device using a new technology intended to ensure high-risk medications are correctly compounded at hospital pharmacies was recently tested at C.S. Mott Children’s Hospital in the University of Michigan Health System. The test showed the device consistently identified and validated the proper formulations of seven intravenous drugs and prevented five potentially serious medication errors over an eighteen month time period.“Errors in compounding these types of medications are rare. However, when they occur they can have a significant negative impact on patients and staff,” said Dr. Jim Stevenson, associate dean of Clinical Sciences at the University of Michigan College of Pharmacy. “We know from having this technology in place we’ve deterred five errors that might have happened. I really believe having technology like this needs to be the standard around the country,” added Dr. Stevenson, who also serves as Pharmacy Services Director at the U-M Health System.
The device uses a process called enhanced photoemission spectrometry to determine if the medication compounds are as intended. A light source from the device energizes the medication under test, which then produces an energy pattern (spectral signature) unique to that drug compound. The device then compares the spectral signature emitted by the medication to its expected signature and determines if it’s a match. The process takes about a minute.
C.S . Mott is the first hospital anywhere in the world to use this technology to validate patient drugs compounded in hospital pharmacies. The U-M Health system already has many safeguards in place, such as barcoding, to prevent medication mistakes.
Although there are many safeguards being pursued to improve patient safety, the principal safeguard used today for intravenous drugs compounded in hospital pharmacies remains a visual verification by the pharmacist, Dr. Stevenson said. However, using a new technology like this helps prevent mistakes caused by human error.
“Our goal needs to be to have zero tolerance for errors,” Dr. 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 failsafe.”
The plan for using this technology to validate medications compounded in hospital pharmacies began in 2004 when Dr. Stevenson learned that a colleague at University of Utah was using a similar system to test narcotics being returned in their operating room. Dr. Stevenson approached the company about developing a new application to verify the accuracy of high-risk intravenous drug compounds prepared in a pharmacy.
The system is now being used at C.S. Mott and University Hospital, both within the U-M Health System. According to Dr. Stevenson, the next step is expanding the number of spectral signatures so that even more medications can be tested.
During the study, the hospital evaluated 40-50 samples per day at strengths and variations above and below the proper dosage amount. The study was recently published, and appears in the Jan. 1, 2008 issue of the American Journal of Health System Pharmacy.
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Source: redOrbit Staff
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