What's the Deal with the Vitamin C in the ICU?

I am noticing more physicians using Vitamin C and thiamine infusion along with steroid for patients with sepsis in the ICU. At first glance, the obvious issues are small sample study, retrospective study, and all patients at one hospital.

NPR's take

Another good one...

Another report

Need More Studies

He wants there to be a comprehensive study, and he said that Stanford University has expressed some interest. But he said it will be difficult to fund because it uses drugs that have been on the market for decades: “We are curing it for $60. No one will make any money off it.”

It will be interesting to see where this leads... if anywhere. But, in the meantime, a little Vitamin C never hurt anyone, right?

Pharmacy Forecast 2016-2020

The ASHP Foundation released a "Pharmacy Forecast: 2016-2020" Strategic Planning Advice back in December. My first thought is a pause thinking how long I have been out of pharmacy school. I start counting on my fingers from '99 and think, wait, what? SEVENTEEN years. I am officially the pharmacist I stood beside in one of my first pharmacy jobs. I considered him wiser. Maybe I am wiser, but I still sometimes feel like school was not too terribly long ago.

This is the fourth edition of this particular report, and I generally try to read every edition. This one somehow slipped by until this past week when I found it and read it rather quickly. There are some applicable topics for today's healthcare pharmacist that I want to dive into.

Strategic Planning versus Reactive Planning

I have not seen a lot of strategic planning within the hospital pharmacy model. We do a lot of reactive planning based on other departments mostly in line with cost management and saving money. We plan operations in how we staff our departments based solely on how many patients are in the hospital but do not use other metrics such how complicated medically is the patient? What if the patient comes in with a chronic infection versus the patient who comes in as a first-time infection? What if the patient has 20 or more home medications on board? Census is more than just number of patients. What if it is measured by a formula of disease states both acute and chronic along with number of hospital admissions in the past 5 years plus number of medications? A patient doesn't equal a patient. Maybe this applies in a surgical patient, but not in a patient with COPD, ARDS and decompensating on a ventilator due to a hospital-acquired infection.

Opening the report is a timely introduction:

"Since the start of the pay-for-performance movement1 and passage of the Patient Protection and Affordable Care Act (ACA), there has been intense pressure on healthcare organizations to improve quality while reducing costs. The stress created by this pressure has been exacerbated by proliferation of expensive specialty medications, egregious price increases for some sole-source drug products, and the escalation of generic drug prices. In response to this environment, many healthcare organizations are pursuing mergers and acquisitions in an attempt to create economies of scale without the cost of new construction. Another tactic is to partner with outside entities such as chain pharmacies."

Specifically what caught my eye this time was the section on work force. Change in practice models claim a shift from inpatient to ambulatory type practice.

"THE SHIFT TO AMBULATORY CARE As healthcare organizations respond to payment reforms that aim to lower costs and improve patient outcomes, health-system pharmacy practice leaders are challenged to optimize the role of the pharmacy work force in new models of care. One area of challenge is the shift in emphasis from inpatient to ambulatory care.1 Reflecting this change, three-fourths of Forecast Panelists (FPs) agreed that over the next five years, in at least 25% of health systems, patient care pharmacists will have umbrella responsibilities for both inpatients and outpatients (survey item 1). Further, 69% agreed that at least 25% of health systems will reallocate 10% or more of inpatient pharmacy positions to ambulatory-care positions (item 2). Consistent with anticipated growth in ambulatory care, 65% of FPs predicted a vacancy rate of greater than 10% for ambulatory-care pharmacy leadership positions over the next five years (item 5). Pharmacy staff development programs should ensure that there are adequate opportunities for education and training in management of ambulatory care pharmacy practice, transitions of care, and medication management of chronic illnesses. "

How do we lose money? Readmissions, using more inpatient days than necessary due to reasons in and out of our control, and not following certain standards that are attached to payment or removed when standards are not met while in-patient. 

Did you notice one thing? The salaries of newly hired entry-level pharmacists will decline by 10% while pharmacist technician salaries will increase?

You know I get excited about this one:

"PHARMACISTS AS PROVIDERS Nearly 80% of FPs predicted that at least 25% of health systems will have a formal plan for including pharmacists, along with nurse practitioners and physicians assistants, in advanced roles that allow primary-care physicians to care for more patients (item 4). Supporting the high level of agreement with this statement is the shortage of primary-care physicians, proposed federal legislation to grant provider status to pharmacists, and the large number of states that authorize pharmacists to establish collaborative practice agreements with physicians. 2 Recent changes in reimbursement rules related to complex chronic care and transitional care management3 support the addition of pharmacists to primary-care teams. Many health systems will be establishing a privileging process for pharmacists to ensure that those with expanded patient care roles have the necessary competence for those roles."

I suggest you read through the report. It is mostly put together through surveys, but has some very timely information for the next 4-5 years in pharmacy.

PHARMACY FORECAST 2016-2020

Sepsis and Septic Shock Guidelines

One of the main guidelines in sepsis is the Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock from 2012 (updating the 2008 guidelines).

Pocket Guide

Key recommendations and suggestions:

• Early quantitative resuscitation of the septic patient during the first 6 hrs after recognition (1C)
• Blood cultures before antibiotic therapy (1C)
• Imaging studies performed to confirm a potential source of infection (UG)
• Administration of broad-spectrum antimicrobials therapy within 1 hr of recognition of septic shock (1B) and severe sepsis without septic shock (1C) as the goal of therapy; reassessment of antimicrobial therapy daily for de-escalation, when appropriate (1B)
• Infection source control with attention to the balance of risks and benefits of the chosen method within 12 hrs of diagnosis (1C)
• Initial fluid resuscitation with crystalloid (1B) and consideration of the addition of albumin in patients who continue to require substantial amounts of crystalloid to maintain adequate mean arterial pressure (2C) and the avoidance of hetastarch formulations (1C)
• Initial fluid challenge in patients with sepsis-induced tissue hypoperfusion and suspicion of hypovolemia to acheive a minimum of 30 mL/kg of crystalloids (more rapid administration and greater amounts of fluid may be needed in some patients) (1C)
• Fluid challenge technique continued as long as hemodynamic improvement, as based on either dynamic or static variables (UG)
• Norepinephrine as the first-choice vasporessor to maintain mean arterial pressure >/= 65 mm Hg (1B)
• Epinephrine when an additional agent is needed to maintain adequate blood pressure (2B)
• Vasopression (0.03 U/min) can be added to NE to either raise MAP to target or to decrease NE dose but should not be used as the initial vasopressor (UG)
• Dopamine is not recommended except in highly selected circumstances (2C)
• Dobutamine infusion administered or added to vasopressor in the presence of a) myocardial dysfunction as suggested by elevated cardiac filling pressures and low cardiac output, or b) ongoing signs of hypoperfusion despite acheiving adequate intravascular volume and adequate MAP (1C)
• Avoiding use of IV hydrocortisone in adult septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability (2C)
• Hemoglobin target of 7-9 g/dL in the absence of tissue hypoperfusion, ischemic coronary artery disease, or acute hemorrhage (1B)
• Low tidal volume (1A) and limiation of inspiratory plateau pressure (1B) for acute respiratory distress syndrome (ARDS)
• Application of at least a minimal amount of positive end-expiratory pressure (PEEP) in ARDS (1B)
• Higher rather than lower level of PEEP for patients with sepsis-induced moderate or severe ARDS (2C)
• Recruitment maneuvers in sepsis patients with severe refractory hypoxemia due to ARDS (2C)
• Prone positioning in sepsis-induced ARDS patients with a PaO2/FIO2 ratio of </= 100 mm Hg in facilities that have experience with such practicees (2C)
• Head-of-bed elevation in mechanically ventilated patients unless contraindicated (1B)
• A conservative fluid strategy for patients with established ARDS who do not have evidence of tissue hypoperfusion (1C)
• Protocols for weaning and sedation (1A)
• Minimizing use of either intermittent bolus sedation or continuous infusion sedation targeting specific titration endpoints (1B)
• Avoidance of neuromuscular blockers if possible in the septic patient without ARDS (1C)
• A short course of neuromuscular blocker (no longer than 48 hours) for patients with early ARDS and a PaO2/FIO2 < 150 mm Hg (2C)
• A protocolized approach to blood glucose management commencing insulin dosing when two consecutive blood glucose levels are > 180 mg/dL, targeting an upper blood glucose </= 180 mg/dL (1A)
• Equivalency of continuous veno-venous hemofiltration or intermittent hemodialysis (2B)
• Prophylaxis for deep vein thrombosis (1B)
• Use of stress ulcer prophylaxis to prevent upper gastrointestinal bleeding in patients with bleeding risk factors (1B)
• Oral or enteral (if necessary) feedings, as tolerated, rathern than either complete fasting or provision of only IV glucose with the first 48 hrs after a diagnosis of severe sepsis/septic shock (2C)
• Addressing goals of care, including treatment plans and end-of-life planning (as appropriate) (1B), as early as feasible, but within 72 hours of intesive care unit admission (2C). 

Safety Culture in Pharmacy

From Pharmacy Times: Safety Culture in Pharmacy

I have never met a pharmacist who intentionally set out to make an error. Most pharmacists are detail-oriented individuals who take their roles seriously.
 
After all, pharmacists are the umpires of the health care game. They enter, verify, and triple check prescriptions, orders, and final products until they are satisfied.
 
Pharmacists make sure that the correct medication is going to the correct patient. I signed up for this when I applied to pharmacy school in 1993.
 
At the time, I didn’t know what I was signing up for except a nice salary. I had no idea about the culture of safety in many medical jobs, or that a career in pharmacy required perfectionism.

Fate would have it that I married a man in safety, as well. While he reduces on-the-job accidents along with the Occupational Safety and Health Administration (OSHA) and other safety organizations, I work in a hospital where helping patients become well is the goal.
 
Nevertheless, the Journal of Patient Safety estimates that more than 400,000 people die each year due to harm in the hospital, making it the fourth leading cause of death in the United States. If this were any other industry, the organization would be shut down until the cause of harm was fixed, but hospitals simultaneously save lives, and so they stay open.

Hospitals have cultures that blame people rather than processes. Blaming people reduces error reporting, which shuts down improvement in processes.
 
Health care needs to view all errors as opportunities to improve systems and processes to catch mistakes caused by human error. Keep in mind that humans build processes, as well.
 
But will blaming people instead of processes ever change?

I asked a pharmacist once why he didn’t report errors. He told me that he only reports the errors that matter.
 
Don’t they all matter, though? Choosing and picking which error to report is looking through a punitive lens rather than a process lens.

I try to make it my practice to report all errors, even my own, because it is the only way to shed light on things that need to be adjusted in the system. If there are duplications missed regularly and a trend develops, the system analysts can figure out how to adjust the alerts to be better.
 
Changing how pharmacists check for errors could help, but if we don’t report, then they don’t know. In the meantime, we shouldn’t pick and choose what we report.

In the automotive industry, safety falls under human resources. Many times, an employee safety group is developed to look at the issues affecting the company.
 
Hospitals should employ the same type of safety group that not only encompasses risk management, information technology, and nursing, but also includes actual clinicians who work with the systems and interact with patients and their orders.
 
There should be multiple pathways provided for employees to bring suggestions and concerns to the group to look at the system and make it better, rather than just reporting errors with no follow-up and breaking down the processes that lead to a particular mishap.

We have processes and rules in place to make hospitals safer, but the culture can be so tainted that no one follows the protocols that are in place. It is true that when you start looking at safety through the lens of culture, you see how challenging it is to change.
 
Safety culture starts at the highest level of an organization and trickles down. If management does not have safety as a priority, then I guarantee you that no one else will.

One of the most damaging messages a pharmacist can receive is leadership mishandling a medical error. If our leaders do not take the time to investigate the systems involved with the error and how the error happened, and instead rush to punitive action toward the clinician, then staff members will become more jaded and less involved.
 
Medical errors are almost always the result of systematic flaws, rather than a person’s incompetence. Rushing to judgment rarely improves safety culture in a hospital and turns clinicians into something worse.

Here’s what a culture of safety in the pharmacy would look like:

Order entry and verification would not be in an area where distractions are abundant. There would be a telephone, but mainly for outbound calls. Order entry/verification would be in a quieter environment separate from where phones are ringing. Why host tasks that require perfection in an area that isn’t conducive to patient safety? If the room isn’t separate, then there will be constant interruptions. Every interruption, while pharmacists are in the middle of doing their job, is a recipe for disaster, just as it is for a nurse on the floor.

There would be continuity of care with work assignments. If pharmacists or nurses are changing hospitals every day, then they never really learn their patients. Processes could also vary from one hospital to another, which can lead to confusion for the clinician. If a pharmacist regularly works in the same environment, then he or she can see what processes need to change to ensure patient safety. Relationships between nursing and physicians would improve due to continuity of care. 

Nurses and pharmacists would report every single error, no matter how small. Only situations where there was blatant disregard of policy or unsafe acts would be punitive. If there is a near miss, then praise, where the error was discovered prior to the patient receiving the wrong care, would be given. The system should be designed to catch errors at different levels, rather than to rely on one step of the process. 
A safety focus group would be set up where issues and processes are analyzed on a routine basis, and changes are evaluated based on these analyzes. This focus group in the pharmacy could report to a larger group in the hospital with each department represented if a particular issue affects other departments.

More: Hospitals Mess Up Medications in Surgery A Lot - Bloomberg Business October 2015

Could a Robot Do Your Job?

Could Artificial Intelligence Replace Pharmacists?

The question that pharmacists need to ask themselves is, “Could my job function be replaced by artificial intelligence?” Many would respond confidently with a no. According to Geoff Colvin of Fortune magazine, author of Talent is Overrated and Humans are Underrated, if your job does not have human behavior in its function, you would be quite surprised to hear you are replaceable. Computers and robots cannot show empathy, compassion, sympathy or collaboration. Artificial intelligence (AI) can check drug-drug interactions, drug-disease state interactions and make recommendations and much more.  AI can check medication compounding and final product with better accuracy than human accuracy. To survive long-term, pharmacists need to provide more than just a final verification with order entry and final product.

Pharmacists’ jobs are a big target for more automation especially since medication errors are a big issue in public health safety. According to the Institute of Medicine, an estimated 7,000 deaths in the U.S. each year are due to preventable medication errors. Medication errors also cost about $16.4 billion annually. Pharmacists are slowly being replaced at the University of California San Francisco Medical Center and are responsible for receiving prescriptions, packaging, and dispensing.

Pharmacists need to collaborate with other healthcare professionals

Pharmacists need working relationships with physicians and other healthcare professionals in the hospital or in the ambulatory care setting. We need to be a valid member of the healthcare team offering real-time advice and recommendations on patients during rounds. We also need improved communication. If we merely sit in a seat in the same room of a hospital entering orders and checking the final product, we could easily be replaced by artificial intelligence.

It becomes even more vital for the Pharmacist Provider Status bill to pass simply to help add billable functions to our role instead of just billing for product. I have no doubt with the right system and hospitals willing to pay for the technology, pharmacists could lose their role in order entry and checking. We make mistakes because we are human and checking is not a complicated process. We already have the potential to allow computer systems to do the allergy checking and drug interaction checking for us without much of a thought. We now have prescribers entering orders directly into the computer. It is not unfathomable for a computer to check what the prescriber entered with much more accuracy than a pharmacist for less money.

Pharmacists need to be involved with direct patient care.

Medication reconciliation is a place where pharmacists could have patient contact and ensure that medications are entered correctly into the electronic medical record. Pharmacists could be more involved in warfarin and diabetic education collaborating with other professionals. Pharmacists could also be involved with educating patients about their medications before they leave the hospital. All of these things do cost money for the hospital since they are mostly not billable, but the pharmacist would be able to do more than what a computer could do alone.

A computer is unable to replace human interaction. Pharmacists need to bring more value to the healthcare table than functions that can be done by artificial intelligence.

CPOE Implementation: A Status Report

Back in 1999, the Institute of Medicine (IOM) published the article "To Err is Human: Building a Safer Health System," which focused on preventing adverse drug events (ADEs).

Computerized Physician Order Entry (CPOE) was touted as a tool to reduce ADEs. Subsequent studies pointed out how it would help prevent medication errors and improve patient safety.

The US government has pushed computerization, as well.

"To improve the quality of our health care while lowering its cost," President Barack Obama said back in January 2009, "we will make the immediate investments necessary to ensure that, within 5 years, all of America's medical records are computerized."

It has now been 6 years, and medical records are still not 100% computerized.

Implementation of CPOE has been slow due to its complexity and huge cost. To further entice hospitals to jump on board with electronic health records (EHR), the US Centers for Medicare and Medicaid Services (CMS) sends money to facilities that meet set goals.

EHR systems are not something that can be rushed, but for dollars, workarounds happen. There is also the threat of penalties if systems are not implemented.

As the EHR market has matured, the once-crowded field of vendors has narrowed significantly.

At the end of 2013, just 10 vendors accounted for about 90% of the hospital EHR market: Epic, MEDITECH, CPSI, Cerner, McKesson, Healthland, Siemens, Healthcare Management Systems, Allscripts and NextGen Healthcare, according to Becker's Hospital Review.

No CPOE standardization

CPOE systems are all different, so how are they compared? A hospital may have implemented a CPOE, but does that equate to a sufficient system? Do groups like Leapfrog take into account CPOE errors or just the percentage of usage by prescribers? Do we rate CPOE systems like we rate hospitals?

Data show vendor CPOE market share, but there are no rating systems to evaluate the systems after implementation, or even a list of hospitals that decided to change systems due to issues.

Limited medication profiles

Another issue with CPOE is its lack of a coherent view of a patient’s profile while entering medications. It is also difficult to verify orders without a comprehensive view of the medications that the patient is taking.

This lack of a full picture causes the user, whether prescriber or verifier, to rely on the software alone, rather than a comprehensive approach. Seeing the whole picture while entering and verifying orders would probably decrease errors.

Alert fatigue

When CPOE systems are used for other tasks aside from entering and verifying orders, there is more alert fatigue.

On the pharmacist verification end, it is common to see alerts of different significance with nothing to differentiate high importance from low. For example, the same type of alert may be used to discuss inventory, prior authorization, and other messages that take away from the verification role, even though many of these alerts previously happened at order entry.

Pharmacists should not have to think pharmacologically and pharmacokinetically about how a medication works along with alerts dealing with inventory, cost, and formulary status that once occurred at the front end. There should be a way to differentiate these alerts and have them fire at appropriate times, rather than during actual medication review. 

Tailoring the CPOE to be more user-friendly for the prescriber often comes at the expense of more frustration on the back-end with verification. For example, a CPOE may allow a prescriber to free type directions for medications taken irregularly (3 days a week, different strengths on different days), choose non-formulary medications rather than built-in CPOE formularies, and remove alerts that need to be seen at order entry.

In this way, verification becomes more of an order entry “fix” role that pulls attention from clinical aspects of verification.

CPOE software is also designed under the assumption that prescribers and verifiers are working in a quiet environment, but both sides are working in noisy environments. When a phone is ringing, a patient is yelling, and a nurse is asking a question, quick pop-up alerts may not be enough of a warning. Even the most focused individual will make mistakes.

More duplicate orders

The Journal of the American Medical Informatics Association published a study pre and post-implementation of a CPOE in an ICU and found that duplicate medication ordering errors increased after implementation (pre: 48 errors, 2.6% total; post: 167 errors, 8.1% total; p<0.0001).

Sometimes, there is a lack of integration between laboratory values, both inpatient and home medications, and other data or different modules that do not communicate smoothly.
 
Last but not least, if the staff is not happy with the CPOE software that is implemented, they are not going to use it as designed. - See more at Pharmacy TImes.

Why Hospital Pharmacy Struggles

It is no surprise to hospital pharmacists that there is an internal battle going on. I cannot outline the struggle without first describing how hospitals get paid. Hospitals are a business and businesses cannot continue to function without money to pay its employees and generate profit.

Hospitals are paid by different methods depending on who is paying the bill.

Medicare: the federal program for the elderly usually pays the hospital a flat fee per case depending on the case. There are around 750 different diagnostic related cases (D.R.G.'s) that can be billed and each command a flat rate regardless of what happens in the hospital. These flat rates are changed due to lobbying and advice from commissions and other methods. Many times hospitals claim the payments received are below cost which causes the hospital to lose money.

Medicaid: the federal-state program for the poor, blind and disabled hospitals receive the same D.R.G's or a set amount of dollars per day (per-diem) or fee-for-service (F.F.S.) payments. These are set by state governments. Again, many times hospitals claim the payments received from Medicaid are below cost which causes profit loss.

Private insurers: purchased by consumers and pay hospitals on the basis of per-diems or fee-for-service. These usually exceed hospitals' costs and help override the losses from Medicare and Medicaid. Private insurers also help with net profits for the hospital and are negotiated yearly.

Breaking down the particular fees agreed upon, it's fairly evident that the pharmacist's role in billable services is on the distribution aspect: the medication provided and the rest is dollars saved but not billed. For example, if I dispense 2 bags of IV vancomycin, the hospital can bill $XX for the medication. If I recommend changing vancomycin to an oral antibiotic, the savings are due to medication and delivery costing less. I am not billing the other aspects of the IV to PO change. The patient has less chance of infection with an antibiotic given by mouth than IV and is easier to administer. Maybe even the cultures drawn show equal sensitivity and the choice of by mouth antibiotic is an ideal choice over choosing IV. There are cost savings for the drug (still distribution in nature) and costs in drug delivery, but the consult itself to change a medication has no billable service to the pharmacy department but indirect savings to the hospital as a whole. There are also cost savings with preventable adverse drug errors in regards to length of hospital stay billed, but nothing billed on catching anything amiss on a patient's profile, rounding with physicians, billing a "consult" or anything tied to a clinical pharmacist directly as a provider.

In other words, pharmacists command high salaries but do not have a way to bill for the same amount in return. Pharmacists and pharmacies cost the hospital a lot of money.

Hospitals are starting to learn that using pharmacists to cut medication errors cuts down on readmission (financial penalties with reimbursement). They are learning that there are costs tied to a patient experiencing an adverse drug reaction and other indirect cost savings, but the hospitals still need a return on their investment. Perhaps that is where provider status for pharmacists will fill in the gap?

Not only do we struggle with what we bill and what we cannot bill, we also struggle with being segmented within our own pharmacy departments. Distributive pharmacists (order entry pharmacists) are looked upon as aging dinosaurs out-of-touch with the clinical aspect of rounding with physicians and making real-time recommendations at bedside and new graduates state, "I don't want an order entry job. I want to be a clinical pharmacist." There is a division that seems to be encouraged with residency programs, fellowships, and board certification leading to "clinical" jobs and none required for order entry jobs. Maybe you are one of the lucky ones in a more progressive hospital that tries hard to incorporate both models into staffing with pharmacists decentralized on the hospital floors interacting "clinically" with nursing, physicians and patients. Maybe you are still stuck to a computer monitor in the basement of a hospital barely interacting with anyone directly. The models are all over the place because of the lack of being able to bill for what pharmacists provide besides a bag of medication.

Another struggle is that clinical pharmacists do not want to be bothered by pharmacy operational problems or regulatory issues. Operational problems affect patient care as well and translates into costs for the department and hospital. 

The last struggle that I have observed over the last fifteen years is the lack of excellence in leadership. I do not have many peers who strive for leadership roles in pharmacy but are fine to sit back and just work as a pharmacist rather than a manager. There are not a lot of strong leaders teaching and mentoring others on how to lead within the pharmacy and because of that pharmacists do not have a lot of power or clout to make change happen inside the pharmacy. This also translates into the lack of leadership and power where change happens on a government level.

What is the answer? I am hopeful that provider status will open the door to pharmacists becoming a return on investment for hospitals rather than a huge expense, but I also believe that there should be more meshing with understanding the business side of hospital pharmacy with clinical pharmacy because the two together would benefit what should be the ultimate goal of a hospital: patient care and minimizing costs.

Pharmacy Distractions

Yesterday, I decided to record the number of distractions I faced on a regular work day. This proved to be a distraction in itself considering the pharmacy where I worked is in an open plan where technicians, phones, cubicles and door to the hospital hallway are all within ten feet of where I sit. There are four or five telephone lines which ring regularly. There are usually one to two other pharmacists sitting within five feet and two to three technicians in the same vicinity.

Yesterday I recorded over 150 interruptions. I even faulted myself for starting personal conversations which distracted others. 

What are some things we can do to make the pharmacy workplace have less distractions? Interruptions contribute to medication errors and having a dedicated space where interruptions are not allowed should be implemented. Chemotherapy entry, preparation and checking definitely falls into this category. The Institute for Safe Medication Practices found that each interruption is associated with a 12.7% increase in errors. I have personally attempted to enter new chemotherapy on a patient in the noisiest place where phones are ringing consistently, technicians are interrupting the workflow with issues on the phone that they cannot handle and other staff are just walking by to chat, all while the TV is reporting the news and a radio in the back is piping out 80s music. It is enough to cause me to go into panic mode. Ask for a dedicated space with less distractions or a no-interruption zone. You may not get it but it is on the record that you asked. In the meantime, one tip I have tried is headphones with something soothing to completely block out all noise when concentration is key. Bose makes great noise-canceling headphones that work! Though I would love to work in silence, blocking out everything but one sound is better than ten sounds all interrupting and distracting what you are trying to do safely. 

Another source of interruptions is when a medication is out-of-stock. This issue can completely lead a pharmacist into a rabbit hole of issues. First I have to ask if we have the medication which leads to comments of inventory failure and what process is to blame. Second we have to call other hospitals and ask to borrow a medication which interrupts them as well. We also have to call a courier service to deliver the medication which leads to delay in delivery of treatment to the patient. If we could reduce missing medications, we could reduce distractions and phone calls. This type of interruption falls under system distractions along with medication timing and other issues that causes distractions on how we handle system failures or deficits.

Alert fatigue is another source of distraction. It is common for me to receive five or more alerts per order when entering a medication with the majority being unnecessary. For example, when entering a sodium chloride IV fluid, I will routinely be alerted that the chloride in the IV fluid will be a duplication with the potassium chloride (chloride duplication). I will also receive an alert that sodium chloride is on national backorder. Most of the times medication alerts include what is formulary, nonformulary, to notify IT staff when medication is depleted, duplication of class that isn't clinically significant, insignificant labs that can include a time period longer than current hospitalization and even how to enter medications differently for a new process that can change quite often. It is used more times than not as an email to communicate inventory issues that should be saved for another time and not when entering a medication where the most important issues are drug, strength, indication, directions and allergies. All of the important stuff can be diluted quickly by things that are nowhere near as important than the task at hand.

Educating the staff is very important in handling distractions and improving patient safety. Educating the staff to know when to interrupt with something important that cannot wait a second and when to write a note for the pharmacist to handle a few minutes later is important. Placing phones with multiple lines in a separate area to lower distractions while the pharmacist is entering orders or checking orders and/or having a designated technician to answer phones and not filling is an idea to consider. Also educating a technician on how to answer the phone and troubleshoot is invaluable!

The Institute for Safe Medication Practices has looked at this issue and has an invaluable write-up about things that can be done to help pharmacists and technicians focus on what matters most... patient safety.

Alert Fatigue; Pop-up Fatigue and Drug Errors

It would be nearly impossible for me to meet the standard rate (number of entries per hour) of many hospital companies and properly investigate every single issue with a particular medication against disease state, interactions with other meds and allergies. We rely heavily on computer programs and screening programs to help facilitate this job. However, with the invention of alerts while we work is the issue of "alert fatigue."

The biggest problem I have encountered over the past several years is the sensitivity of alerts. I frequently not only get alerts for the things I NEED to know but the things that are not nearly as important. I receive an alert daily for Sodium Chloride 0.9% IV fluid and Potassium Chloride when entering the two.  The interaction is "chloride." Keep in mind, the potassium chloride is actually compounded into sodium chloride. This is mixed in with more important alerts like what the patient's potassium level really is. I also receive alerts about what is formulary and non formulary, what is in stock, what is on backorder, if I need to add an NDC to something for billing, if I need to pick another strength, if the med can only be ordered by one doctor and not another, and so on. This is all mixed in with the same level of importance as creatinine with metformin, INRs for warfarin, allergies entered, height and weight of the patient, and so on. With at least ten alerts per order and around fifty orders per hour, we are nearing 500 alerts per hour all the while answering phone calls, questions from the staff and people just walking into the room to chat and say hi. It's no wonder I feel so distracted.

The problem with this methodology is that we lose the real alerts that are important. Comparing an alert for someone with hyperkalemia with ordering potassium replacement vs letting me know that I need to change the potassium to another NDC vs that the med is on back-order is really changing the way the system was intended. Also, is anyone monitoring all the alerts that are bypassed daily? Is anyone noticing these and monitoring trends? 

Too many alerts turn into noise.

I know that if all facilities would start an initiative to reduce alerts, alerts would have more meaning and pharmacists would probably react more to the alert. 

And maybe... less errors. 

With the implementation of CPOE, this issue has risen to the forefront of what prescribers must wade through in selecting the best medication therapy for their patients. While the industry worries about prescribers becoming complacent to alerts due to overly sensitive drug-drug interactions or drug-allergy interactions, pharmacists have been battling this for years. Prescribers seemingly must worry about the meds and patients whilst pharmacists are wading through the leftover messages with safety along with pharmacoeconomic issues.

1. Alerts should be tiered. Level 1, 2, 3, etc or color coded based on severity.  Never allow one sweeping override reason count for multiple alerts.

2. Alerts that have nothing to do with patient safety, formulary comments, billing issues should be reserved at another level not mixed in with potentially life-saving messages!

Adding financial notes with the already overburdened system of patient safety is a recipe for disaster both in patient safety and also for pharmacist job satisfaction. 

ISMP mentions this: "Protect against ALERT FATIGUE through fewer, more appropriate alerts that need consideration by pharmacists before filling the prescriptions.

Optimize the sensitivity of alert systems by carefully selecting alert severity levels and allowing only the most significant alerts to appear on the screen during data entry." 

3. Hard stops should be built for certain high risk interactions (even if the money doesn't exist to build). 

4. Someone in the department should be trending overrides. What are the trends? Can the system be improved without waiting for an event that causes injury?

5. Allow pharmacists who use the system daily to report alerts that are not needed.  

"Encourage the reporting of invalid or insignificant warnings so they can be altered or removed from the computer system." -ISMP

This is a great article on alert fatigue from our perspective.