The pharmacy professional's guide to products and career opportunities

nsiderSpring 2007

Pharmacy

TM

Relating 2007National PatientSafety Goals to

your practice, p.2

Looking at hybridvs. decentralized

systems, p.6

Harmful errors:How your facilityshould respond,

p.10

In the news, p.1Legal lookout, p.9

Relating 2007National PatientSafety Goals to

your practice, p.2

Looking at hybridvs. decentralized

systems, p.6

Harmful errors:How your facilityshould respond,

p.10

In the news, p.1Legal lookout, p.9

Spring 2007 1 Pharmacy Insider

Hospital pharmacieshaving trouble hiring experiencedpharmacistsAccording to the latest annual staffingsurvey from the ASHP, pharmacymanagers in hospital and health sys-tems are having trouble filling posi-tions with experienced frontlinepharmacists. Among the other find-ings in the survey of pharmacy direc-tors at 597 U.S. hospitals and healthsystems: • 87% of respondents perceive ashortage of pharmacy managers.• The average vacancy rate for phar-macists in 2006 was 7%.• Almost 50% of respondents notedgreater use of nontraditional staffingmodels, particularly in larger hospi-tals, including compressed work week(54%), team scheduling (48%), andjob sharing (45%).

To obtain a copy of the survey,go to http://www.ashp.org/emplibrary/StaffingSurvey2006.pdf.

Source: http://www.ashp.org/s_ashp/sec_press_article.asp?CID=168&DID=2037&id=17706.

New publications• Medication Errors, 2nd edition,edited by Michael R. Cohen(http://www.ismp.org/products/medErrsEd2/default.asp)• USP30-NF25, a three-volume print

format and enhanced online and CDfeatures, is available to order in Eng-lish (http://www.usp.org/products/USPNF) or Spanish (http://www.usp.org/products/USPNF/spanishEdition.html)

New resource for pharmacistsThere’s a new section on The JointCommission’s Web site that’s de-signed for pharmacists at http://www.jointcommission.org/ Pharmacists/default.htm. It in-cludes articles from Joint Commis-sion Resources’ publications, reviewsand updates on standards, FAQs,and safety and quality issues impor-tant to pharmacists.

Also new on the site is a revised

list of look-alike/ sound-alike drugs.For the complete listing, includingpotential errors and consequencesand specific safety strategies, visithttp://www. jointcommission.org/NR/rdonlyres/ C92AAB3F-A9BD-431C-8628-11DD 2D1D53CC/o/Revised_LASA_list_ 200607.pdf.

The public trusts youWhen asked to rate how trustwor-thy and ethical various professionalsare, 73% of respondents to an an-nual Gallup poll indicated “veryhigh” or “high” for druggists/pharmacists. Only nurses ratedhigher (84%). Car salesmen hit bot-tom at 7%.

Source: Honesty/Ethics in professions, Gallup Poll, 2006,http://www.galluppoll.com/content/default.aspx?ci=1654.

In the news

Watching the newsFor updates on patient and medication safety, tune in free to the FDA Patient Safety News each month. This televised series for health careprofessionals is carried on satellite broadcast networks. It appears on many health care education networks and on the FDA Patient SafetyNews Web page, http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/psn/index.cfm. Each monthly broadcast covers new medical prod-ucts, FDA recalls and safety alerts, patient teaching, and error prevention. If you can’t watch the video, you can review the index and readinformation featured in current and previous programs.

Salary results inThe Fall 2006 National Pharmacy Compensation Survey report of 104 orga-nizations includes these key results:

Position title Hourly Annual (Specialization: Hospital/Health care) base pay* base pay**

Pharmacy team manager $53.65 $111.60

Staff pharmacist (retail,hospital, health care retail/satellite, mail-order/online); clinical pharmacist; nuclear pharmacist $46.52 $96.80

Lead pharmacy tech, pharmacy tech $14.18 $29.50*Weighted mean

**Weighted mean in thousands

Source: Pharmacy Week, 1/10/07, http://www.pharmacyweek.com.

Pharmacy Insider 2 Spring 2007

While undergoing cerebral angiography, a 69-year-old pa-tient was accidentally injected with an antiseptic skin prep so-lution, chlorhexidine, instead of a contrast medium. The clearchlorhexidine had been placed on the sterile field in an un-labeled basin identical to that used to hold the clear contrastmedium. At the end of the procedure, the contrast mediumshould have been injected into the patient’s artery for radi-ographic visualization.

Instead, the chlorhexidine was drawn into the syringeand injected into the patient.

Chlorhexidine is highly toxic when injected intravascu-larly and the patient experienced acute, severe chemical in-jury to the blood vessels of her leg. Over the following 2 weeks,her condition deteriorated. She underwent a leg amputation,then suffered a stroke and multiple organ failure, which killedher.

As revealed when this incident was investigated, thehospital had recently switched antiseptics from a brownpovidone-iodine solution to a clear chlorhexidine one. Thisdecision ultimately resulted in a latent failure—two look-alike, clear solutions that were previously distinguished bycolor placed in unlabeled basins on the sterile field.1

To help organizations prevent medication errors like this,The Joint Commission established National Patient SafetyGoals (NPSGs) and made them part of the accreditationrequirements. NPSGs highlight problematic areas in healthcare and promote specific patient-safety improvements.The goals are derived from information on sentinel eventsreported to The Joint Commission and from recommen-dations made by the Sentinel Event Advisory Group thatworks with the commission to determine and create goalsand related requirements.2 This article will discuss NPSGsthat focus on the medication-use process and affect phar-macists working in acute care settings.

Goal 2: Improving communicationAs one of the original NPSGs, Goal 2 strives to improve theeffectiveness of communication among caregivers. Re-quirement 2B advocates creating a standardized list of ab-breviations, acronyms, symbols, and dose designations thatorganizations shouldn’t use.

Throughout the years, the Institute for Safe MedicationPractices (ISMP) has warned about the dangers associatedwith using certain abbreviations when communicatingmedication information. For example, the abbreviation “U”for “units” has often been misread as a zero, resulting intenfold overdoses of medications such as insulin.

The best way to avoid using dangerous abbreviationsis establishing and enforcing policies for written and oralorders.3 Avoiding these dangerous abbreviations and

Looking at the NPSGs thataffect pharmacy practiceLearn which of the National Patient Safety Goals directly affect yourpractice—and the best ways to meet them.By Kelly Stanforth, PHARMD, and Matthew Grissinger, RPH, FASCP

Abbreviations from the official “Do Not Use” list15

U (unit)

IU (International unit)

Q.D., QD, q.d., qd (daily)

Q.O.D., QOD, q.o.d., qod (every other day)

Trailing zero (X.0 mg)*

Lack of leading zero (.X mg)

MS

MSO4 and MgSO4

*Exception: A “trailing zero” may be used only where required todemonstrate the level of precision of the value being reported, such asfor laboratory results, imaging studies that report size of lesions, orcatheter/tube sizes. It may not be used in medication orders or othermedication-related documentation.

Spring 2007 3 Pharmacy Insider

dose expressions in other communications—includingcomputer-generated labels, medication administrationrecords, labels for drug storage bins/shelves, preprinted or-ders and protocols, and computerized pharmacy and pre-scriber order entry programs—is equally important.However, many computer systems display drug doses us-ing naked decimal points or a trailing zero and may usedangerous abbreviations, such as QD and U. So misinter-preting orders remains a very real possibility even with ad-vanced technology solutions such as computerizedphysician order entry (CPOE).4

Goal 3: Safe medication useNational Patient Safety Goal 3 is directed at promoting thesafe use of medications. Requirement 3B of this goal statesthat institutions must standardize and limit the number ofdrug concentrations used in their institution. This require-ment has been a challenge for hospitals whose nursing andhouse staff use the Rule of 6 to calculate and prepare solu-tions that are dosed in microgram per kilogram perminute. The formula for the Rule of 6, as referenced in TheHarriet Lane Handbook, is 6 multiplied by the patient’sweight (in kilograms) equals the amount of drug in mil-ligrams that should be added to 100 mL of solution. Theinfusion volume in milliliters per hour then equals the mi-crogram per kilogram per minute dose ordered, and re-sults in multiple concentrations of medications to beinfused in patient care areas. One of the problems with theRule of 6 is that some nurses use the formula for intra-venous (I.V.) admixture, a risky procedure that bypassespharmacy preparation and subsequent double-check sys-tems to verify accuracy. This method also adds a mathe-matical calculation, which is always error-prone if donemanually.5 In 2004, ISMP reported on an infant who diedas a result of a calculation error that occurred when a deci-mal point was misplaced. The dopamine infusion preparedwas 10 times more concentrated than intended.6 Withproblems like these in mind, hospitals need to adopt stan-

dard concentrations for solutions, abandon use of the Ruleof 6, and have the pharmacy prepare and dispense pre-mixed I.V. solutions while on site.3

The second medication-related requirement of Goal 3,3C, requires that facilities identify and annually review a listof look-alike/sound-alike drugs and take action to preventmix-ups. The list must contain a minimum of 10 drugcombinations.2 The Joint Commission has released an up-dated list of look-alike/sound-alike medications for 2006-20077 (available online at http://www.jointcommission.org/NR/rdonlyres/C92AAB3F-A9BD-431C-8628-11DD2D1D53CC/0/LASA.pdf).

Various strategies can minimize the risk of look-alike/sound-alike errors. For example, determine whichname pairs are problematic in your organization and don’tstore these drugs alphabetically by name; arrange them outof alpha order or put one of them in an alternate location.Encourage prescribers to provide both the generic andbrand names of drugs that are problematic and to write themedication’s purpose on the medication orders. This willhelp you screen for proper doses, duration, and appropri-ateness. Also, when taking oral orders, first write down theorder, then clearly read back the name of the drug and thedosage ordered, and request or provide correct spelling ofthe medication name.9

Problematic look-alike and sound-alikedrug names

ephedrine – epinephrine

hydrocodone – oxycodone

hydromorphone injection – morphine injection

hydroxyzine – hydralazine

MS Contin – OxyContin

OxyContin – oxycodone

tramadol – trazadone

Don’t mix up these opioids

Over the years, ISMP has received many reports ofconfusion between HYDROmorphone and morphine,some of which have described fatalities. In fact, mix-ups between these drugs are among the most com-mon and serious look-alike errors that can occurinvolving high-alert drugs. Some practitioners mis-takenly believe that HYDROmorphone is the genericname for morphine. However, these products aren’tinterchangeable; 1.5 mg of I.V. HYDROmorphone isequianalgesic to 10 mg of I.V. morphine.8

One such mix-up involved a 32-year-old womanwho was admitted to a hospital with abdominal pain.For her pain, she was ordered 1 mg of I.V. HYDRO-morphone every 2 hours as needed. Throughout theevening, the patient continued to complain of pain,and her dose of I.V. HYDROmorphone was increasedto 2-4 mg every 2 hours as needed. After two dosesof 4 mg, the patient continued to report a pain ratingof 10 on a 1-10 rating scale. The physician, thinking 1mg of morphine was equal to 1 mg of HYDRO-morphone, ordered 4-6 mg of I.V. morphine every 2hours. After two doses of 6 mg I.V. morphine, thepatient experienced respiratory arrest. She recoveredbut required ventilator support for 24 hours.

Pharmacy Insider 4 Spring 2007Pharmacy Insider 4 Spring 2007

The final requirement of this goal, 3D, calls for the la-beling of all medications, medication containers (such assyringes, medicine cups, basins), and other solutions bothon and off the sterile field. Unlabeled medications and so-lutions have caused many errors, some with tragic out-comes, such as the report described at the beginning of thisarticle.

To facilitate labeling, consider purchasing sterilemarkers, blank labels, and preprinted labels that can beopened onto the sterile field during procedures to markbowls of solutions and syringes. If drug or solution namesare similar, use tall man lettering on the labels to differenti-ate them or highlight/circle the distinguishing informationof the label. Also, individually verify each medication andcomplete its preparation for administration, delivery to thesterile field, and labeling on the field before you prepareanother medication for use.1

Goal 8: Medication reconciliationIn 2005, Goal 8 was introduced directing accredited organi-zations to completely reconcile medications across the con-tinuum of care—in other words, to develop a process for“medication reconciliation.” This process entails creating acomplete list of the patient’s current medications upon en-try to the health care organization. This list is to be used byclinicians when ordering new medications and when re-ordering a medication if a patient is admitted to a facility.Clinicians compare any medications ordered for that pa-tient to those on the list and resolve any discrepancies.When the patient’s level of care changes (for example, whenhe transfers from a surgical unit to the intensive care unit)or upon discharge or transfer to another facility, his profileand new list of medications is reconciled and sent to hisnext provider of health care services.10

The medication reconciliation process isn’t new; thepractice of collecting a medication list from a patient hasbeen a standard of practice for years. Unfortunately, ithasn’t prevented errors that have occurred because of failedcommunication during transition points in the continuumof care. Here’s an example: ISMP learned of an error inwhich Pamelor (nortriptyline) was prescribed for a newlyadmitted patient. While clarifying another order with thepatient’s pharmacy several days later, a pharmacist learnedthat the patient had been taking Panlor (acetaminophen,caffeine, dihydrocodeine) at home, not Pamelor.11 Error re-ports like this one serve as a compelling reason for estab-lishing this NPSG to help prevent similar errors.

Most practitioners agree with the value of medicationreconciliation, but they’re also frustrated by the difficultiesthey face implementing the processes in their facility. In arecent ISMP survey of over 1,400 health care practitioners,

91% of respondents were familiar with the medicationreconciliation NPSG, but only 75% had attended staff-development sessions about the process. In addition, manyof the respondents were unsure of the time in which med-ications must be reconciled. Thirty-six percent of nurseswere unsure of the required time frame, as were 63% ofpractitioners working in outpatient/office settings. Re-spondents in the survey indicated that teamwork amongdisciplines and clearly defined protocols are important fac-tors for a successful medication reconciliation process. Themost significant barriers encountered by all respondentsincluded unreliable reports from patients and lack ofphysician leadership.12

NPSGs requiring pharmacy’s involvementAlthough some goals, such as those discussed above, arespecifically directed at improving medication safety, otherNPSGs apply to the medication use process and requireparticipation of the pharmacy department.

For instance, Goal 1 aims to improve the accuracy ofpatient identification. The intent of the goal is to reliablyidentify a patient as the person for whom a service or treat-ment is intended and to match the service or treatment tohim.13

The most common scenario of a patient-identificationerror is when a nurse walks into a patient’s room and ad-ministers medications intended for Patient A to Patient B.However, identification errors can originate during anyphase in the medication use process. For example, phar-macists select the correct patient profile in the pharmacycomputer system by entering either the patient’s name oridentification number. But poor visibility of the patient’sname and number on paper order copies (often via ad-dressograph imprint), compounded by look-alike lastnames, has occasionally resulted in entering orders into thewrong patient profile.

A pharmacist reported a similar error to ISMP with adifferent twist. To enter a new order for a patient we’ll callFranklin Hope, a pharmacist tried to access the profile us-ing the identification number. However, the number washard to read, and he couldn’t locate the profile. He thenentered the patient’s name, Franklin Hope, and a profileappeared on the screen. While entering the order, thepharmacist happened to notice that the patient was female,not male. He soon realized that he’d been entering the or-der into Hope Franklin’s profile, not Franklin Hope’s!14

To help prevent patient identification errors, pharma-cists and pharmacy technicians should compare the pa-tient’s name and identification number on the computerprofile to that on the order when entering medication or-

Spring 2007 5 Pharmacy Insider

ders. Enlarging the size of the patient’s name on the screenalso can improve the accuracy of CPOE. Replacing addres-sograph imprints with laser-printed identification stickersto improve clarity is another option.4

Even if problems aren’t obvious in your facility to-day, every facility can anticipate and focus on problemsby complying with NPSGs, discussing errors that havehappened at other facilities, and incorporating the risk-reduction strategies presented in this article. n

REFERENCES1. Institute for Safe Medication Practices (ISMP). Loud wake-upcall: Unlabeled containers lead to patient’s death. MedicationSafety Alert! 9(24):1-3, December 2, 2004.2. The Joint Commission. Introduction to the National PatientSafety Goals. http://jointcommission.org/PatientSafety/NationalPatientSafetyGoals/npsg_intro.htm. Accessed March 19, 2007.3. The Joint Commission. Medication errors related to potentiallydangerous abbreviations. Sentinel Event Alert. 23, September 1, 2001.4. ISMP. Please don’t sleep through this wake-up call. MedicationSafety Alert! 6(9):1, May 2, 2001.5. ISMP. Standard concentrations are safer than using Rule of 6.Medication Safety Alert! 8(16):1-2, August 7, 2003.6. ISMP. Avoid preparing infusions using the Rule of 6 or Brose-low tape. Medication Safety Alert! 10(4):2-3, February 24, 2005.7. The Joint Commission. 2006-2007 Look-Alike/Sound-Alike DrugsList. http://www.jointcommission.org/NR/rdonlyres/C92AAB3F-A9BD-431C-8628-11DD2D1D53CC/0/LASA.pdf. Accessed March19, 2007.8. ISMP. An omnipresent risk of morphine-hydromorphone mix-ups. Medication Safety Alert! 9(13):1-2, July 1, 2004.9. The Joint Commission. Look-alike, sound-alike drug names.Sentinel Event Alert. 19, May 1, 2001. 10. ISMP. JCAHO and you: What is medication reconciliation?Medication Safety Alert! Community/Ambulatory Edition, 5(11):1-2, November 2006.11. ISMP. Building a case for medication reconciliation. Medica-tion Safety Alert! 10(8):1-2, April 21, 2005.12. ISMP. Practitioners agree on medication reconciliation value,but frustration and difficulties abound. Medication Safety Alert!11(14):1-2, July 13, 2006.13. The Joint Commission. FAQs for The Joint Commission’s2007 National Patient Safety Goals. http://www.jointcommission.org/NR/rdonlyres/49313BED-3D00-4740-A5D7-91900A6052A3/0/07_NPSG_FAQs_1.pdf. Accessed March 19, 2007.14. ISMP. Oops, sorry, wrong patient! Applying the JCAHO “two-identifier” rule beyond the patient’s room. Medication SafetyAlert! 9(11):1-2, June 3, 2004.15. The Joint Commission. Official “Do Not Use” List. http://www.jointcommision.org/NR/rdonlyres/2329F8F5-6EC5-4E21_B932-54B2B7D53F00/0/06_dnu-list.pdf. Accessed April 3, 2007.

Kelly Stanforth is safe medication management fellow and Matthew Grissingeris a medication safety analyst at the Institute for Safe Medication Practices,Huntingdon Valley, Pa.

Pharmacy Insider 6 Spring 2007

Medication safety by the numbersAt St. John’s Regional Medical Center, a hybrid medicationdistribution model adds up to safer care at lower cost.

By Jack W. Udell, PharmD, RPH, ABE

SPURRED BY QUALITY, regulatory compliance, and fi-nancial pressures, administrators at U.S. hospitals rightlyare focusing more attention on the impact of medicationmanagement on patient care. There’s also a growing em-phasis on freeing pharmacists from dispensing duties inthe central pharmacy and moving them into consultingroles with patients, physicians, and nurses, where they canpositively influence prescribing patterns.1,2

At St. John’s Regional Medical Center in Joplin, Mo., a367-bed community hospital, we’re ahead of the curve inmany medication management respects, thanks in large partto technology we adopted. Just 6 years ago, our medicationdistribution system was incredibly labor intensive, requiring16 pharmacists and 15 technicians to manually dispenseabout 1,600 doses per day. We had a very time-consumingdaily cart fill process that consumed about 13.5 full-timeequivalent (FTE) staff. We used a pneumatic tube systemthat delivered all orders that were “first dose,” “now,” and“stat” to the nursing floor, and we did all filling by hand.Each day, we had scores of returned medications and dozensof missing medications. Constantly filling orders and field-ing phone calls from nurses, we were too busy to have a clin-ical program. Clearly, we needed to make a change.

Pharmacy models to choose fromThe American Society of Health-System Pharmacists 2006National Survey of Pharmacy Practice in Hospital Settings3

defined two models for distributing drugs—centralizedmanual distribution, in which medications are manuallydistributed from central pharmacy to nursing units, anddecentralized distribution, in which nurses retrieve 85% to95% of patient medications from medication cabinets onpatient floors, which pharmacy staff manually replenish.

But I suggest a third model—hybrid distribution. Usingautomation technology, such as robotics or carousel tech-nology, central pharmacy provides 85% to 95% of medica-tions to nurses in bar-coded, patient-specific form. Nursesretrieve opioids, p.r.n. medications, and some first dosesfrom a vastly reduced medication cabinet footprint.

After reviewing the literature, examining data, attend-ing conferences and seminars, consulting with peers, con-ducting site visits, and completing a thorough businesscase analysis, we concluded that hybrid distribution, withits bar-coding foundation and inherent safety and produc-tivity benefits, was clearly what we wanted to develop.

In presenting our case to hospital administration, weprojected that our new, hybrid distribution system wouldreduce dispensing errors and increase pharmacists’ interven-tion. We projected a cost of $1.2 million over 6 years but wealso anticipated saving the hospital $400,000 in the first yearalone. In reality, we surpassed that first-year savings targetby $28,000, and we’ve continued to see increased benefitsevery year since. To quantify our savings, our accountingdepartment looked at the type of interventions our pharma-cists make and put a dollar value on them, based on the lit-erature. For example, dollar values were established forinitiating a more cost-effective therapy or dosing a drugbased on renal function; in addition, preventing a major ad-verse drug reaction was given a higher dollar value thanpreventing a minor one.

Dispensing to 99.9% accuracyWe redesigned our pharmacy team processes around abar-code-based, hybrid distribution system. In the centralpharmacy, we introduced ROBOT-Rx, McKesson’s roboticdispensing system, to automate the storage, dispensing, re-turning, restocking, and crediting of bar-coded medica-tions. To prepare all of our medications in bar-coded,unit-dose form, we instituted McKesson’s PakPlus-Rxpackaging service, which also serves as an inherent qualitycheck, helping prevent dispensing errors. Our PakPlus-Rxtechnicians apply bar codes to all of our medications at arate of about 600 unit doses per hour. All doses must passthrough a five-point check before entering inventory.

Automating our systems saved us a lot of time and di-rectly correlated to improved medication safety. It let usreengineer our processes and redeploy pharmacy staff toroles where they can interact with clinicians and directly

Spring 2007 7 Pharmacy Insider

impact the quality of patient care.From day one, ROBOT-Rx, operated by pharmacy

technicians, has automated the dispensing of nearly 94% ofunit-dose solid medications and single-dose vials. Overall,daily cart fill time has declined from 13.5 FTE hours to 3 FTE hours, including manual picks. The robot also dis-penses between 65% and 75% of first doses.

The robot dispenses to 99.9% accuracy. In fact, theMissouri Board of Pharmacy, like those in about 24 otherstates, has granted a waiver for a full pharmacist qualitycheck for those facilities using ROBOT-Rx. Even so, ourpharmacists perform a 5% random check. Our robot hasnever picked a wrong dose, a wrong strength, or a wrongmedication; the only errors occur when it’s dropped a dosebefore putting it into a cassette or when it grabbed twopackages instead of one. These problems occur only rarely.

Except for intravenous (I.V.) medications, opioids,and some oral liquids, all medications are dispensed fromthe central pharmacy in bar-coded form in containers per-sonalized for each patient. Missing medication rates aredown 75% over the past 5 years, expired medications havebeen reduced, and we reduced our cart fill dispensing errorrate from 2.5% to less than 0.1%.

These results, along with improved turnaround times,have greatly improved nursing satisfaction and boosted phar-macy’s standing throughout the hospital. Nurses are confi-dent that they’re getting the right medications in the rightdose for a specific patient in a timely manner. And they likehaving a pharmacist on the floor to resolve any questionsabout drugs—and give them more time for patient care.

We still have room in our hybrid distribution modelfor medication cabinets, although we have a much smallercabinet footprint than other hospitals our size. We have 29medication cabinets located on the nursing units. Nursesuse these for some first doses, as well as for opioids, p.r.n.medications, and floorstock items.

More recently, we added two MedCarousel units tocentral pharmacy. Their bar-code technology and pick-to-light feature, which directs technicians and pharmacists tothe appropriate location, help reduce the risk of medica-tion picking and restocking errors. We use the carousels tofill cabinets, for manual picks for cart fill and first doses,and for inventory control.

All automation systems are interfaced so that if anitem isn’t stocked in the robot, it automatically queuesup the carousel. This makes managing systems, runningreports, and evaluating system effectiveness easier.

Pharmacists taking on clinical rolesWithout a doubt, the most dramatic outcome enabled byour hybrid medication dispensing system—and the area

most beneficial to our patients and the hospital—is our re-designed clinical pharmacy practice. Automation let us re-deploy our pharmacists from dispensing activities toclinical roles. For most of our staff pharmacists, this was thefirst time they were part of a clinical care team. So, to start,we conducted extensive training on our outcome goals, in-cluding clinical assessments; economic evaluations; and hu-manistic outcomes such as patient satisfaction, adversedrug reactions, and quality of life. We had staff pharmacistsshadow the hospital’s clinical pharmacists.

We established clear protocols for ensuring effectivedrug therapy. We covered such responsibilities as changingor clarifying medication orders, eliminating therapeuticduplications, evaluating drug–drug interactions, andavoiding adverse drug events. We also included participat-ing in formulary conversions, recommending medications,providing pharmacokinetic consults, making therapeuticsubstitutions, and reporting medication error and druglevels. Next, we set forth rigorous documentation require-ments, gained independent cost validation through our fi-nance department, and committed to frequent analysis forcontinuous improvement.

Staff pharmacists embraced their new responsibilities.Today, we have three clinical pharmacists, each spending40-plus hours per week on the nursing units. Combined,they perform more than 3,200 patient-pharmacist inter-ventions each year. By decentralizing our staff and increas-ing other clinical activities, our department documented atotal of 10,249 accepted interventions during 2006. Job sat-isfaction and retention improved immediately and haveheld strong in the past 5 years. One pharmacist has re-turned to college to earn his PharmD degree and is now re-sponsible for our critical care area. Furthermore, theimpact made by our patient-pharmacist interventions hasprompted physicians, nurses, and others on the patientcare teams to ask us to increase our clinical presence. Noneof this would have been possible without the hybrid distri-bution system.

The bottom line: Saving moneyHere are three potential financial disadvantages with thedecentralized model.

1. It stores up to 95% of medications in cabinets, so,for example, a 400-bed hospital would need 25 to 30 addi-tional cabinets, costing as much as $125,000 per year.4 That40% larger cabinet footprint provides poor asset produc-tivity and no return on investment. Furthermore, to fillthose cabinets, hospitals have to increase their annual drugexpenditures.

2. It relies on expensive nurse labor for medication re-trieval, which costs more and takes nurses away from pa-

Pharmacy Insider 8 Spring 2007

tient care activities—up to 45 minutes per nurse, per shift.5

3. It keeps pharmacists in the pharmacy, performingorder entry, quality checks, and other dispensing duties.Because bar coding isn’t required, the decentralized modeldoesn’t adequately position hospitals for these initiatives.

In conclusion, automation has decreased our medica-tion waste and given us much better control over our in-ventory; we’ve had an 8% increase in drug expense perdose dispensed, despite double-digit inflation on most pre-scription drugs. Through pharmacy interventions, we re-ported cost savings to our hospital of $75,000 per monthduring 2006, proving a direct correlation between pharma-cist involvement and dollar savings. Most important, pa-tient care has improved as pharmacists are more involvedin clinical care. These cumulative savings in terms of im-proved efficiencies, redirected capital assets, and savingsgained through improved patient safety enabled us to real-ize a documented return on our hybrid system investmentin less than 3 years. Today, our pharmacy workflow re-volves around our automation systems.

At St. John’s, like other hospital pharmacies, workloadincreases are a way of life. Between 2002 and 2006, we saw

a 15% jump in the number of doses dispensed. Increasedregulatory requirements now consume much more of ourtime. However, our automation systems have the capacityto easily handle this extra workload without impactingFTEs. Clearly, our hybrid distribution model has beenhighly successful. The numbers speak for themselves. n

Jack W. Udell is the pharmacy director for pharmacy services, St. John’sRegional Medical Center, Joplin, Mo. He also serves as an adjunct professorfor the College of Pharmacy, University Medical Center at Kansas City, Mo.,and at Drake University, Des Moines, Iowa.

REFERENCES1. Pedersen CA, et al. ASHP national survey of pharmacy practicein acute care settings: Monitoring, patient education, and well-ness—2000. American Journal of Health-System Pharmacy.57(23):2171–2187, December 1, 2000.2. Pedersen CA, et al. ASHP national survey of pharmacy practicein hospital settings: Prescribing and transcribing—2001. AmericanJournal of Health-System Pharmacy. 58(23):2251–2266, December1, 2001.3. Pedersen CA, et al. ASHP national survey of pharmacy practice inhospital settings: Dispensing and administration—2005. AmericanJournal of Health-System Pharmacy. 63(4):327-345, February 15,2006.4. Shack & Tulloch. Case Study: The Pharmacy-to-Bedside HybridMedication Distribution System. 11, 2006. 5. Shack & Tulloch. Case Study: The Pharmacy-to-Bedside HybridMedication Distribution System. 9, 2006.

Spring 2007 9 Pharmacy Insider

Legal lookoutStay up-to-date and informed on industry practices,legal trends, and more.

Understanding theresponsibilities andrisks of moving intomanagementMoving into management is a greatway to advance your career, but it’snot without risk. If you decide totake the next step in your career,make sure you understand whatnew responsibilities it will entail.Review the job description and re-quired qualifications for the man-agement position. Determinewhether your skills can supportthese new duties.

Also, make sure your trainingand education prepare you for thejob. You may need some inservicetraining or want to take some man-agerial training courses on your owntime to fill in gaps in your back-ground. Remember, performing tasksthat are beyond your scope of prac-tice or your job responsibilities canpose a liability risk.

If you’ll be supervising others, getfamiliar with the competencies andassigned duties of all staff members.To help protect them from liability,review their job descriptions andwhat procedures their licenses letthem do. Consider making necessarychanges to protect you, the staff, andthe facility from a lawsuit.

Both you and your staff shouldbe familiar with the chain of com-mand and where you fit into it. If

problems occur or questions arise,you should know where to turn.

Finally, know your facility’s poli-cies and procedures and be awarethat violating them can have conse-quences. Get familiar with yourstate’s employment and practicelaws, as well as your employer’s poli-cies. If you’ll have hiring and firingauthority, for example, you’ll have tounderstand how to properly main-tain employee files and what you canand can’t say when interviewing po-tential staff or terminating a subordi-nate.

What if you’re asked tobe an expert witness?An expert witness helps jurors deter-mine if a defendant maintained thestandard of care or acted in the sameway a reasonable and prudent healthcare professional with a similar back-ground would have acted in similarcircumstances. Before you agree totestify as an expert witness in a mal-practice case, make sure you under-stand what’s expected of you.

If you decide that you may wantto offer your services, ask yourselfthese questions:• Am I qualified?• Do I feel comfortable with the at-torney handling the case?• Am I sure I have no conflicts ofinterest—such as having worked pre-viously with the defendant—that

would make me a less-than-idealwitness?• Am I well versed in my specialty’sstandards of care?

If you answered “yes” to thesequestions, you may be well suited tobe an expert witness. You’d be askedto review copies of medical recordsand other documents relevant to thecase and provide an opinion about ifand how a standard of care was met,as well as other related matters. Ifyour opinion supports the attorney’sposition, you’d most likely be askedto testify.

If you do serve as an expert wit-ness, practice your testimony withthe attorney before getting on thewitness stand. Avoid looking too re-hearsed, which could jeopardize yourcredibility. Answer questions objec-tively, honestly, and succinctly.Don’t volunteer information or pro-vide testimony outside your area ofexpertise. Speak firmly, try to uselanguage that laypeople in the court-room will understand, and explainany clinical or technical terms.Above all, make sure your profes-sional liability insurance includes aconsulting services endorsement,which provides protection if yourtestimony results in a claim beingbrought against you. n

Source: Reprinted from the HPSO Risk Advisor, 2006,Pharmacist version, with permission from HealthcareProviders Service Organization, http://www.hpso.com.

Pharmacy Insider 10 Spring 2007

Harmful errors: How willyour facility respond?If you don’t have a plan, here’s where to start.

TO HELP GUIDE the most appropriate response to aharmful error, all practice sites should have a well-designedplan that’s fully supported by the organization, includingthe board of trustees, executive leaders, professional staff,risk managers and attorneys, human resources and staffdevelopment personnel, public relations staff, and middlemanagers. The plan should address the following:• Internal notification. Who needs to be notified about theevent internally, such as the physician, manager, seniorleaders, board of trustees, risk management, patient safetyofficer, director of pharmacy (for a drug-related event),and professional staff? Who provides that notification?How should staff report a harmful event to risk manage-ment? What’s the timeline for notification of the event?How will affected staff be notified about the event? Howare staff and the board updated about the investigation andaction plan? How will internal public relations activities beconducted so that appropriate staff know the story andhow it’s being addressed? • External notification. As required, who’ll notify externalorganizations, such as the department of health and thestate reporting program, about the event? Who will the or-ganization voluntarily notify, such as The Joint Commis-sion, U.S. Pharmacopeia—Institute for Safe MedicationPractices (USP-ISMP) Medication Errors Reporting Pro-gram, and product or device manufacturers, so others cantake precautions to prevent similar errors? How should information about the causes of the event be handled ac-cording to state peer review statutes? How will the organi-zation accommodate visits from regulatory or investigativebodies? • Disclosure. What specifically should be disclosed to pa-tients and families? Examples to consider include the cir-cumstances of the event, consequences to the patient,treatment given, plans for investigation, system-basedcauses, improvement efforts, other parties informed aboutthe event, and contact information for support and coun-seling from the organization and from external sources.Who should disclose the information? How should the dis-

closure happen and who should be present? Who’ll be thecontact person for follow-up or to answer the patient’s orfamily’s questions? How is just compensation for injuriesdetermined and offered to the patient or family? Whoshould inquire about the patient’s or family’s desires aboutthe level of disclosure to the public, and how will that in-formation be communicated to all who need to know?• Treatment of staff. How will staff involved in the eventbe evaluated and treated? How will system-wide account-ability be assessed? What support and psychological coun-seling will be offered to those involved and affected? • Interaction with patients. How should staff—both thoseinvolved and those not involved in the event—interactwith patients and families who’ve been victims of a harm-ful error? How should staff interact with other patientswho’ve heard about the event? • Media inquiries. With inquiries from the news media,how can the organization provide useful and accurate in-formation to the public without breaching patient confi-dentiality? Who’ll provide ongoing feedback to thecommunity? How should staff respond to unsolicited me-dia questions?• Investigation. What procedures must be undertaken tosafeguard documents and involved containers and equip-ment for further investigation? How should the immediateinternal review and investigation of an event be carriedout? How should a more detailed event analysis occur?What criteria will be used to determine whether an inde-pendent review of the event by outside experts should becarried out? How will the results of the investigation becommunicated to the patient or family, applicable staff, theboard, and the public, if appropriate? • Improvement. What process(es) will be used to ensurethat appropriate immediate and long-term preventativeactions are taken, such as ongoing evaluation of actionplan implementation, policy development, and measure-ment to determine positive or negative change? nSource: Reprinted with permission from the Institute for Safe Medication Practices. Harm-ful errors. How will your facility respond. Available at: http://www.ismp.org/Newsletters/acutecare/articles/20061005.asp?ptr=y. © 2006 ISMP. Last accessed April 15, 2007.

Pharmacy Insider 16 Spring 2007

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