A device tested at U-M to eliminate mistakes made while mixing compounds at the hospital pharmacy was 100-percent accurate in identifying the proper formulations of seven intravenous drugs.
Use of new drug testing technology like this could have averted the accidental overdose of film star Dennis Quaid’s newborn twins last month. The twins were given 10,000 units instead of 10 units of a blood thinner called heparin. They since have recovered.
In the U-M research, five potentially serious medication errors were averted over an 18-month period at C.S. Mott Children’s Hospital in the U-M Health System (UMHS) by using the technology, says Jim Stevenson, associate dean of Clinical Sciences at the School of Pharmacy. Stevenson, who also directs Pharmacy Services at UMHS, says the hospital is the first in the world to use this device to test patient drugs compounded in the pharmacy.
“Errors in compounding these types of medications are rare. However, when they occur they can have a significant negative impact on patients and staff,” Stevenson says. “We know from having this technology in place we’ve deterred five errors that might have happened. I really believe having technology like this needs to be the standard around the country.”
The table-top device manufactured by ValiMed, a division of Tuscon, Ariz.-based CDEX Inc., uses a technique called enhanced photoemission spectroscopy to determine if the compounds are correct. Light is shot into the drug compound, which excites molecules, and the energy emitted by the excited molecules is measured by a spectrometer. Each drug compound tested has its own so-called light fingerprint, which is compared to the fingerprint of the control compound. If they match, the drug is considered correct.
There are many potential safeguards that are being pursued to improve medication safety, such as bar coding, to ensure the correct drugs and doses are administered, Stevenson says. The primary safeguard for intravenous drugs compounded in hospital pharmacies today, however, remains a visual check by the pharmacist. Using a technology like this helps prevent mistakes that can occur due to human error.
“We think these occurrences are very infrequent, but when they do happen they can have significant negative impact on the patient. Our goal needs to be to have zero tolerance for errors,” Stevenson says. “If we wanted to eliminate errors completely we knew we couldn’t continue to rely completely on human visual checking. We needed to implement some sort of technological solution to overlay our human process for these drugs to be failsafe.”
The hospital tested 40-50 samples daily, at strengths and at variations below and above the proper dosage amount. The process takes about a minute, so the technology was integrated into the workflow of the pharmacy when used for select high-risk products. The paper, “Enhanced photoemission spectroscopy for verification of high-risk IV medications,” appears in the Jan. 1 issue of the American Journal of Health System Pharmacy.
While the device now is used at C.S. Mott and University hospitals, the next step, Stevenson says, is for the company to develop more signatures so that more drugs can be tested.
The idea for the project started in 2004 when Stevenson got word that a colleague at the University of Utah was using a similar device to test narcotics being returned in their operating room. Stevenson contacted the company about developing applications to check intravenous drug compounds prepared in the pharmacy for accuracy. The company agreed and began developing the signatures for the compounds to be tested.
