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. 

The Problem with Pradaxa

For the second time in four years, the authors of the RE-LY (Randomized Evaluation of Long-term anticoagulant therapY) Trial have revised the number of deaths (added 20) due to serious adverse events within the clinical trial that tested the drug on patients.

Pradaxa (dabigatran) is approved by the FDA for preventing stroke in nonvalvular atrial fibrillation only.

The RE-LY trial was divided in three arms: (18,000 patients in over 40 countries) - 1,400 died in the original trial. 

• 110 mg dabigatran twice daily - 4 cases of life-threatening bleeding that led to three deaths
• 150 mg dabigatran twice daily - 4 cases cases of life-threatening bleeding that led to two deaths
• standard warfarin - 3 cases of life-threatening bleeding that led to all three dying

What is so great about dabigatran? There are no levels to manage as in warfarin. A patient has to endure weekly INR checks and adjustments along with monitoring other medications taken and diet to keep INR therapeutic. Dabigatran has no lab monitoring involved.

What is so bad about dabigatran? There is no antidote, so if you do get in a situation where you are bleeding, the consequences are much more dire. The company that makes dabigatran states they are working on developing an antidote but that even without one, they say they match warfarin's rate of death. According to the ISMP, 542 patients died in 2011 taking Pradaxa. 

In the same category, Xarelto (rivaroxaban) is FDA approved to treat DVT and PE and prevention of stroke in nonvalvlular atrial fibrillation. Eliquis (apixaban) is FDA approved for DVT, nonvalvular atrial fibrillation and post-op venous thromboprophylaxis following hip or knee replacement surgery.

How could the FDA approve a medication without an antidote?

Atrial Fibrillation and Anticoagulation

What is Atrial Fibrillation? 

Risk factors for AF include:

• Age
• Hypertension
• Diabetes mellitus
• MI
• VHD
• HF
• Obesity
• Sleep apnea
• Cardiothoracic surgery
• Smoking
• Exercise
• Alcohol
• Hyperthyroidism
• Increased pulse pressure
• European ancestry
• Family history

The issue with atrial fibrillation is that blood pools in the heart due to inefficient pumping and can cause a clot to form which can lead to a stroke.

Antithrombotic therapy should be individualized. Selection of therapy is based on the risk of clot regardless of AF pattern. In patients with nonvalvular AF, the CHA2DS2-VASc score is recommended for assessment of stroke risk.

Mechanical heart valvles:  warfarin is recommended and the INR goal of 2.0-3.0 or 2.5-3.5 depends up on the type/location of prosthesis.

If patient has had a stroke with nonvalvular AF, TIAs, or a CHA2DS2-VASc score of 2 or greater, oral anticoagulants are recommended in this order: warfarin (INR 2-3), dabigatran/rivaroxaban/apixaban.

Warfarin measure INR at least weekly during start of treatment and monthly when stable.

Bridging therapy: bridge with UFH or LMWH recommended for patients with AF and a mechanical heart valve undergoing procedures that require interruption of warfarin.

If patient doesn't have a mechanical valve, balance the risk of stroke vs. bleeding.

In the new anticoagulants, renal function should be re-evaluated when indicated and at least annually. For example, if you have a patient with end-stage CKD needing AF anticoagulation, warfarin would be the optimal choice since the newer agents are dependent upon renal clearance.

If CHA2DS2-VASc score is 0, you can omit antithrombotic therapy.

If CHA2DS2-VASc score is 1, no antithrombotic therapy or treatment with an oral anticoagulant or Aspirin may be considered.

Do not use dabigatran in patients with AF and a mechanical heart valve.

CHADS2 Acronym - maximum points = 6

• Congestive HF:  Score 1
• Hypertension:  Score 1
• Age >/= 75 y:  Score 1
• Diabetes mellitus: Score 1
• Stroke/TIA/TE:  Score 2

CHA2DS2-VASc Acronym - maximum points = 9

• Congestive HF: Score 1
• Hypertension: Score 1
• Age >/= 75 y:  Score 2
• DM:  Score 1
• Stroke/TIA/TE: Score 2
• Vascular disease (prior MI, PAD, or aortic plaque): Score 1
• Age 65-74: Score 1
• Sex category (i.e., female sex): Score 1

Warfarin or one of the newer anticoagulants (in non-valvular AF)?  It seems now that the newer agents are preferred unless the patient is comfortable with INR measurements, wants the lower drug cost of warfarin, or patients with chronic kidney disease.  If patient has valvular AF, use warfarin.

The question is how do you define non-valvular AF vs valvular AF? For some valvular means mechanical prosthetic and rheumatic mitral disease.

Trials on the subject:

RE-LY Trial

Rocket AF Trial

Aristotle Trial

Allopurinol and 6-mercaptopurine (6-MP) Drug Interaction

Allopurinol is a medication used for gout and hyperuricemia associated with cancer treatment that has a potentially devastating interaction with 6-mercaptopurine (6-MP). 6-MP is used in ulcerative colitis and crohn's disease along with being a part of a chemotherapy treatment.

In the news recently, a patient was admitted to the hospital with a blister on her foot and subsequently died of an infection. The patient was taking 6-MP for colitis and started on allopurinol for gout. Allopurinol blocks one of the enzymes that metabolizes 6-MP, xanthine oxidase thus causing more of the active metabolites which have an effect on WBC replication/activation and/or suppression of ras-related C3 botulinum toxin substrate 1 (Rac 1) which can facilitate apoptosis (programmed cell death) of WBC's. The patient would then become neutropenic which could lead to death. Hematologic toxicity can be exacerbated by other medications which inhibit TPMT (another metabolizer of 6-MP to an inactive metabolite) like mesalamine or sulfasalazine.

 

Flu Season is Upon Us! Pediatric Recommendations

According to the American Academy of Pediatrics (AAP), the influenza vaccine not only prevents seasonal flu, but also reduces sick days, antibiotic use, and physician visits.  It also reduces the risk of hospitalization and death.  

The AAP's updated recommendation reflects changes in available vaccines.  Here is another nice table of available products for the season upon us.  Under the 2014-2015 recommendations, children between the ages of 6 months to 8 years should receive 2 influenza vaccines separated by a minimum of 4 weeks. You can use the live attenuated influenza vaccine for those aged 2-8 years, though watch contraindications to live (children using aspirin or aspirin-containing medications, children younger than 2, immunocompromised children, or a history of asthma/wheezing).

In our household, we are planning on the live attenuated because of demonstrated superior efficacy over inactivated in preventing influenza among children according to a study back in 2007. 

Here are some common misconceptions about the flu vaccine.  
 

California Pharmacists Will Soon Dispense Naloxone for Opioid Overdose

California legislation will soon allow pharmacists to dispense naloxone without a prescription for opioid overdose according to the Pharmacy Naloxone Bill (AB 1535).

Naloxone is an opioid antagonist that competes and displaces opioids at opiod receptor sites. In opioid overdose, adults would take 0.4 to 2 mg IV every 2-3 minutes as needed. Repeated doses may be needed every 20 to 60 minutes, bit if no response is observed after 10 mg, the diagnosis should be questioned. Adverse reactions are mostly related to reversal of dependency/withdrawal including GI, cardiovascular, CNS and respiratory effects. 

Beginning January 1, 2015, California pharmacists can furnish naloxone to family members of patients at risk for overdose, those who might be in contact with someone at risk for OD, or anyone who requests the drug. Guidelines will be developed by the state's boards of pharmacy and medicine.

This is a great step for pharmacists combating a problem: drug overdoses.  Drug overdoses kill more people each year than either cars or guns. In 2010, the CDC reported, 38,329 people died of drug overdoses (mostly opioid related).

Read this article from back in February by Maia Szalavitz with Time Magazine, "Wider Use of Antidote Could Lower Overdose Deaths by Nearly 50%."

Remaining Relevant in an Saturated Market

Photo courtesy of https://www.flickr.com/photos/nevadastate/

ASHP has set a goal for 2020 that all pharmacists involved in direct patient care should have residencies. This makes me confused because aren’t we all involved in direct patient care if we work in a hospital? What are the odds that a pharmacist who has been out of school for over ten years would find it beneficial  to complete a pharmacy residency? Does fifteen years of experience mean anything? Were non-PharmDs made to go back to school that extra year to practice direct care? As it is there are not enough residencies to fill current graduates much less the more experienced pharmacists.

In the past, pharmacists were chosen for clinical positions in hospitals based on experience. I experienced many pharmacists earning their way to a different position by learning on-the-job. Isn’t that what residencies are? What is the difference? One difference is the money. Hospitals are making money on residents. They are paid half the salary of a regular staff pharmacist and then find reimbursement from the government. They are given the jobs that cannot be done with normal staffing due to corporations limiting staffing due to budgets. After a year, these “residency-trained” pharmacists leave their position for another residency or mostly hired right in the same hospital where they completed on-the-job half-the-price training for a whole year. This is a large sacrifice for some pharmacists but with the thousands graduating with over $100,000 in debt and a requirement looming for all to have a residency on their CV, it is becoming a no-brainer.

One of the things I have noticed as a pharmacist over the past 14 years is that experience is becoming less and less valued and the initials behind one’s name more valued. If you did a residency, you are a little better off than the ones who didn’t regardless of where or what hospital sponsored the residency.  The irony of this is that non-resident pharmacists are training residents. If it is good enough for the residents, isn’t it good enough for the patients?  I can see the need for more specialized training in the scope of a practitioner (i.e., nurse practitioner type position) but not in the current setting where we write orders based on P&T approved protocols and scopes of practice that are signed by MDs. We are utilized as cost conscientious employees changing a patient’s medication from IV to oral to save some money. We slash and burn certain therapies based on approvals. Why would I need additional training for these functions above and beyond what I have learned in the past fourteen years?

I am an advocate for keeping up with the industry.  Do not for the love of all things pharmacy sign up for a free CE live opportunity and just wait on the music to get the credit.  You are cheating yourself.  Think about it, while you are sitting in your BS or PharmD non-residency non-BCPS life letting the new updates and guidelines passing you by dumping questions on who has been designated “clinical” in your department, you are losing ground.  We are not safe, guys.  This mandate makes me nervous because it COULD happen, “I’m sorry we are no longer allowing those that work here without a PGY-1 continue.”  I know the odds seem low, but read this idea of residency equivalency for those of us without one who may want to compete.  This is what ASHP has to say about it:

“1109:  RESIDENCY EQUIVALENCY:  https://www.ashp.org/DocLibrary/BestPractices/EducationPositions.aspx

                Source: Council on Education and Workforce Development – to acknowledge the distinct role of ASHP-accredited residency training in preparing pharmacists to be direct patient-care providers; further, to recognize the importance of clinical experience in developing practitioner expertise; further, to affirm that there are no objective means to convert or express clinical experience as equivalent to or a substitute for the successful completion of an ASHP-accredited residency.

                Rationale: ASHP’s position on the need for residency-trained pharmacists is well established and described in the ASHP Long-Range Vision for the Pharmacy Workforce in Hospitals and Health Systems.  It has been suggested that a way to achieve the goal of having all pharmacists in direct patient-care roles be residency trained would be to establish a process for reviewing a “portfolio” against pre-established criteria to grant a “residency equivalency.” The Council, Board, and House concluded that both residency training and experience are important and valuable, but different, and that it would not be appropriate to create a process that attempts to convert one into the other.  The intent of the goal of having all new college of pharmacy graduates who provide direct patient care residency trained by 2020 is to enhance the skills of those practitioners, and the creation of a residency equivalency process might dilute the value of that residency training and undermine achievement of the goal. The Council, Board, and House also discussed the process used by ASHP to waive the requirement for a postgraduate year one (PGY1) residency directly. While the process does consider total experience in granting the waiver, and may seem to contradict the recommended policy, the applicant still completes a residency, ultimately gaining those experiences unique to residency training.”

I do notice that the statement “all new college of pharmacy graduates who provide direct patient care…” may protect me, but does it?

ACCP (American College of Clinical Pharmacy), another agency, commented on the postgraduate year one pharmacy residency program equivalency.  http://www.accp.com/docs/positions/commentaries/Jordan_PGY1.pdf

“Although ACCP continues to strongly advocate the importance of these postgraduate training programs in preparing a competent clinician, nontraditional approaches to evaluate the abilities of seasoned pharmacists who have not completed residency training are needed. Hence, in 2006, the Task Force on Residency Equivalency was created and charged to (1) define the professional experience that should serve as “postgraduate year one (PGY1) residency equivalency,” (2) determine qualitatively and quantitatively the experience that practitioners could document by a “residency equivalency portfolio,” and (3) identify mechanisms for filling the gaps that exist between a practitioner’s experience and the existing standard for PGY1 pharmacy residency programs.”

Guide for Residency Equivalency Portfolio Development:

                ACCP encourages the development of a residency equivalency portfolio.  What should this contain?  ACCP recommends three things:

• A personal statement
• Self-assessment
• Personal goals and objectives for the future
• Reasons for pursuing residency equivalency certification
• Accomplishments and activities
• Education
• Work experience
• Licensure status
• Publications
• Relevant personal statements
• Verification of the success of those activities through supporting documents and feedback from colleagues.

What is the answer?  I still stand by ACCP’s vision of BCPS certification perhaps being equivalent or at least seemingly equivalent to a residency (maybe with or without valid experience?).  Since ASHP is responsible for accrediting residencies, they will not see value in the more experienced pharmacist and how they can be grandfathered in with a BCPS. 

Did we not run into this same thing back when PharmDs arrived on the Bachelor of Pharmacy scene?  Perhaps the problem of too many graduates makes it much easier to say a residency is required to find the type of work we have been doing all along.  With 20% of new graduates having a hard time finding employment, I think it is vital that current pharmacists keep up-to-date with current guidelines and remain the "fittest."  What does this mean?  It means being involved in pharmacy organizations, challenging yourself with certification (most popular ACCP), and doing everything possible to keep from being labeled as less capable.

DVT Prophylaxis in the Hospital: Why is It Important?

Photo credit: Ross G. Strachan (Creative Commons)

Venous thromboembolism is a topic that touches most hospital staff in some way. I decided to delve into the topic of DVT/PE to do a little research for myself in answering questions and at the same time hope to shed more light on this cause of 10% of hospital deaths that is very preventable.  

Some of the risk factors for VTE include stasis, hypercoagulability and endothelial damage. Stasis includes age > 40, CHF, stroke, anesthesia, immobility, obesity and other conditions'. Hypercoagulability includes cancer, high estrogen, inflammatory bowel, nephrotic syndrome, sepsis, smoking and pregnancy. Surgery, prior VTE and trauma are other examples.  It should be fairly obvious after thinking about risk factors that most patients in the hospital will have at least one risk factor for VTE.

A study in Lancet showed that out of around 70,000 patients in 358 hospitals, appropriate prophylaxis was administered in 58.5% of surgical patients and only 39.5 % of medical patients.  (Cohen, Tapson, Bergmann, et al. Venous thromboembolism and risk and prophylaxis int he acute hospital care setting (ENDORSE study): a multinational cross-sectional study. Lancet 2008; 371: 387-94.

Who is paying attention? The NQF "(National Quality Forum) is a not-for-profit, nonpartisan, membership-based organization that works to catalyze improvements in healthcare."  The Joint Commission is also watching.  We all know who TJC is right?  TJC has their own core measures that hospitals are monitoring for VTE prophylaxis.  Here are some of the standards released in the past few years with the last being a summary (though a bit on the long side).

• The Annals of Internal Medicine published an article (clinical guideline) a couple of years ago called Venous Thromboembolism Prophylaxis in Hopsitalized Patients: A Clinical Practice Guideline From the American College of Physicians.
• CHEST released their 2012 Executive Summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. 
• Here is the summary of the same from CHEST: Antithrombotic Therapy and Prevention of Thrombosis 9th Edition: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines.
• AHRQ: National Guideline Clearinghouse Venous Thromboembolism Prophylaxis

A.S.P.E.N.'s Parenteral Nutrition Handbook, 2nd Edition

Click on image to order A.S.P.E.N.'s Parenteral Nutrition Handbook, 2nd Edition (no paid link on this, just for your information)

            As a pharmacist and a clinician at my local hospital, there have been times where I am starting a new PN (total parenteral nutrition) and needed help beyond the usual formula or write-up that we use. In the information age, we have a diverse amount of information online at our fingertips; however sometimes this information can be from sources that are not legitimate. I can google PN and a disease state and hope for something relevant, or I can seek out material that is tried, true and tested.

            The A.S.P.E.N. Parenteral Nutrition Handbook, 2nd Edition is a pocket-sized handbook or quick reference that covers many parenteral nutrition topics with students in dietetics, nursing, medicine and pharmacy in mind. There are 10 fully revised chapters from the 2009 1st edition including: 

1.  Chapter 1: Nutrition Screening, Assessment, and Plan of Care

2.   Chapter 2:  Overview of Parenteral Nutrition

3.   Chapter 3:  Parenteral Nutrition Access Devices

4.   Chapter 4:  Parenteral Nutrition Formulations and Managing Component Shortages

5.   Chapter 5:  How to Prescribe Parenteral Nutrition Therapy

6.   Chapter 6:  Review and Verification of Parenteral Nutrition Orders, Preparing Parenteral Formulations, and Ordering

7.   Chapter 7:  Parenteral Nutrition Administration and Monitoring

8.  Chapter 8:  Complications of Parenteral Nutrition

9.  Chapter 9:  Medication-Related Interactions

10.  Chapter 10:  Home Parenteral Nutrition Support

These chapters cover many of the relevant topics for the patient receiving parenteral nutrition (PN) including some newer topics on order review, compounding, and drug shortage management. Also this handbook contains evidence-based guidelines from the A.S.P.E.N. Parenteral Nutrition Safety Consensus Recommendations (JPEN, March 2014) and A.S.P.E.N. Clinical Guidelines: Parenteral Nutrition Ordering, Order Review, Compounding, Labeling, and Dispensing (JPEN, March 2014).

I have taken the time to utilize this handbook while dosing PNs in the past few weeks and have found this reference accurate while covering many of the topics I needed.  I especially enjoyed the chapter on parenteral nutrition complications.  I found the topics succinct and spot-on for finding quick information on a couple of questions I had on a patient’s PN.

If you are looking for a guide with a broad range of topics related to PN that will help your student, resident or even new pharmacist managing PN, this guide will help you tremendously.

The Balancing Act

iStock photo by KatarzynaBialasiewicz

I apologize ahead of time that this isn't my usual post, but I figure since 70% of my pharmacy graduating class of 1999 were female that we could relate to the balancing life of work and motherhood.

From the time my alarm clock sounds at 5:00-5:15 AM until the time I clock in at work at 7 AM, I spend about fifteen minutes on myself getting ready.  I have mastered the art of putting on my makeup in about five minutes flat in the parking lot of the hospital.  Every traffic signal and every car on the road can either make or break my timing to make it to work on time.  With school starting back up in about a month, I am already dreading leaving the house earlier to account for the school buses that will slow me down.  Work has become a break from the chaotic life shuttling kids to and from school and activities, making lunch boxes and keeping a tidy home.

I find myself thinking negatively of myself quite a bit.  I think that I fail doing any of my roles well (mother, wife, pharmacist).  I feel spread thin; I am trying to give as much of myself but there is not much left.  I have to add and ask, "How do you single mothers do it?"

I am sorry I woke up late this morning - too late to handle the dog's long bathroom trips and cooking breakfast.  I made the lunchboxes, but there is nothing in there very healthy.  I threw in a pack of chips as a filler.  I am sorry that I don't have anything planned for dinner, the yard needs mowing and the car needs washing.  I'm sorry the laundry is not done.  I'm sorry we won't have any fun after school due to homework.  I'm sorry I can't stay late at work, the kids are sick I can't be there and I have no sitter next week when school and summer camp are out.  I am sorry I seem to always be in a bad mood at home, I don't fix myself up and my kids need dentist appointments.  I'm sorry I forgot the last checkup with my daughter.  I have to gather all the school supplies that fit onto two full pages for both kids and find time during my workday to make a meet and greet and registration.  No kids are allowed either.  Guess I'll just have to take them with me because not everyone is a stay-at-home mom.

There I said it.  Not everyone is a stay-at-home-mom.  I know I am judged by them sometimes with "we sacrificed for them" and other comments.  I have the unforgiving schedule of the hourly worker.  Yes, I am a pharmacist with a BS and Pharm.D., but I still clock in and out like the hourly worker down the street serving me lunch and cannot just leave at will.  Instead of expecting myself to do what no one else can do, I have started noticing the culture.  It's time for working mothers to realize they are doing a damn good job.  Even me.

We have to make things better.  I am the first to admit that I do not know how... maybe acceptance?

Some resources:

Working and Raising Kids Pretty Much Sucks in America (not my title but click the link by another blogger)

The Ten Secrets of One Unflappable Working Mother

I like this one:  For Working Moms, Key to Balance May Lie in Elusive Leisure Time

The Modern Balancing Act