Assessment of final product dosing accuracy when using volumetric technique in the preparation of chemotherapy.

BACKGROUND: Studies have compared gravimetric and volumetric dosing accuracies in chemotherapy agents, finding high accuracy in gravimetric measurements with a mean deviation of ± 0.06%, while volumetric measurements had a mean deviation of ± 3.02%. METHODS: Chemotherapy doses prepared under a biological safety cabinet containing two weights from the precision scale between 15 December 2010 and 30 March 2011 were eligible for inclusion. Empty syringes attached to a closed-system transfer device were weighed prior to product manipulation. The product was then prepared using the syringe pull-back method (volumetric technique) and the same syringe containing drug was weighed (gravimetric method). RESULTS: A total of 1156 compounded sterile products were eligible for the study. The mean percent volume difference of preparations included was -0.53% with a range of -64.9% to 94.22% for individual doses. Of the prepared doses, 71.7% were within ± 5% and 87.4% were within ± 10% of the ordered dose. Secondary outcomes found to be associated with an increased percent volume difference were the pediatric population, smaller volumes prepared, drugs requiring reconstitution compared to already in solution, and final product dispensed to the patient in syringes. CONCLUSION: While the mean value of volumetric measurements is within the generally understood acceptable range for dispensing chemotherapy, the range of measurements is highly variable. Future studies are warranted to better understand the reasons behind the variation and to evaluate the impact of workflow changes on improving final product accuracy.

Significant Publications About the Medication Use Process in 2012.

PURPOSE: This article identifies, prioritizes, and summarizes the published literature on the medication use process (MUP) from calendar year 2012 that can impact health-system pharmacists' daily practice. SUMMARY: The MUP is the foundational system that provides the framework for safe patient care within the health care environment. The MUP is defined in this article as having the following components: prescribing/transcribing, dispensing, administration, and monitoring. A PubMed search was conducted in January 2013 for calendar year 2012 using targeted Medical Subject Headings (MeSH) keywords, providing a total of 944 articles. A thorough review identified 46 potentially significant articles: 14 for prescribing/transcribing, 12 for dispensing, 10 for administration, and 10 for monitoring. Peer review led to the selection of key articles from each category. These articles are briefly summarized, with a mention of why this article is important within health-system pharmacy. The other articles are listed for further review and evaluation. CONCLUSION: It is important to routinely review the published literature and to incorporate significant findings into daily practice. Health-system pharmacists have an active role in improving the MUP in their institution and awareness of the significant published studies can assist in changing practice at the institutional level.

Method to determine allocation of clinical pharmacist resources.

PURPOSE: An objective methodology to guide decisions by hospital pharmacy departments on the best use of clinical pharmacist personnel is described. SUMMARY: To help determine the optimal deployment of state-licensed Clinical Pharmacist Specialist (CPS) staff, a task force led by the pharmacy department at University of North Carolina (UNC) Hospitals developed an objective approach to evaluating the relative need for and potential impact of CPS expertise within the medical center's many service units. After analyzing several years of patient census and medication-use data and using information from proprietary databases (Thomson Reuters) to calculate a "service-specific pharmacy intensity score" for each hospital service, the task force identified five staff-allocation metrics best suited to the medical center's service-based pharmacy coverage model. By applying the methodology, it was determined that CPS expertise was most needed in the UNC Hospitals adult medicine oncology service, the bone marrow transplant service, and the medical and neonatal intensive care units. The tool was initially used to validate the pharmacy department's existing human resource allocation and has since been used to guide budgeting for and deployment of newly added CPS positions. CONCLUSION: A novel tool to guide the application of pharmacy human resources incorporates the objective criteria of patient census, patient acuity, teaching involvement, drug expenditures, and use of high-risk medications. The tool can be used to determine the appropriate allocation and placement of clinical pharmacist resources in a service-based coverage model.

Implementation of continuous infusion of blood coagulation factors at an academic medical center.

PURPOSE: A multidisciplinary initiative to promote more cost-effective use of blood factor derivatives and increase pharmacist involvement in associated order verification, dispensing, and monitoring activities is described. SUMMARY: After an evaluation of a hospital's procedures for the use of blood factor derivatives identified inconsistencies and opportunities for cost savings, a revised medication-use process promoting continuous infusion of selected products (factors VIII, IX, and VIII/von Willebrand factor) was developed by pharmacy staff with input from physicians and nurse educators. The implementation of the enhanced medication-use procedures included (1) the publication of a compendium of key information on commonly used blood factors, including specific guidance on dosing and administration, (2) the use of Web-based educational modules targeting pharmacists and nurses, (3) greater involvement by pharmacists in blood factor order justification and verification, (4) routine pharmacist assessment of pertinent laboratory values and other determinants of optimal dosing, and (5) refined procedures for changing i.v. tubing. Surveys of pharmacists conducted before and after the practice changes indicated a significant increase in their knowledge of blood factor products and evidence-based best practices for the management of hemophilia. CONCLUSION: Through a multidisciplinary initiative involving pharmacists, physicians, and nurses, new procedures to promote continuous infusion of selected blood factor products were implemented. Results of a postimplementation survey indicated that educational tools were effective in increasing pharmacists' knowledge of blood factor derivatives and hemophilia management.

Global formulary review: how do we integrate pharmacogenomic information?

OBJECTIVE: To summarize a standard formulary decision process and provide recommendations for the integration of pharmacogenomic (PGx) information within the formulary decision-making process. DATA SOURCES: With use of MEDLINE (1920-March 2010), the terms "formularies, hospital" and "pharmacogenetics" were searched in the MeSH database, yielding no results. The MeSH terms were then searched separately in addition to searching for "rational drug therapy" and "essential medicines list" through the main PubMed database. STUDY SELECTION AND DATA EXTRACTION: Articles deemed relevant to both terms were assessed, interpreted, and incorporated as key pieces to the review of formularies and the integration of PGx information as a part of the formulary review process. The articles referenced were deemed appropriate and categorized into 5 areas: formulary management systems and pharmacy and therapeutics (P&T) committees, international formularies, formulary decision-making, PGx evidence, and recommendations regarding integrating PGx into formulary decision-making. DATA SYNTHESIS: The field of PGx is rapidly evolving as the evidence supporting genetically guided individualized therapy continues to grow. To bring this evidence from the bench to the bedside, institutions will need to evaluate PGx data to integrate individualized therapy into practice. Few standardized methods exist to analyze and apply clinical PGx data and incorporate the information into drug evaluation at the formulary level. Several online sites provide resources to aid in formulary review and can be used when incorporating clinically relevant PGx information into a formulary decision. In addition, there are key questions that organizations can ask as they evaluate the PGx information in each step of the decision-making process. CONCLUSIONS: P&T committees should formulate a plan to integrate a search for pharmacogenomic data with each drug evaluation and integrate the results into the formulary decision process to enhance the appraisal of drug efficacy, safety, and cost.

Evaluating an approach to improving the adoption rate of wireless drug library updates for smart pumps.

PURPOSE: An academic medical center's approach to improving the adoption rate of wireless drug library updates for smart pumps was evaluated. SUMMARY: A multidisciplinary team composed of pharmacy, nursing, medical engineering, materials management, and patient equipment personnel at an academic medical center collaborated to update the drug libraries of more than 1800 smart pumps via a wireless control system. Two pilot tests were completed to identify and resolve issues before the live wireless update was attempted. The second pilot test, a passive approach, produced an adoption rate of 42% of 1804 pumps at the end of one week and a rate of 56% on day 10. The goal of 80% was not achieved until day 22. The change to an active multidisciplinary process three months later produced an adoption rate of 80% for 1869 pumps on day 10, resulting in a 45.4% increase in the adoption rate between the two trials on day 10 (p < 0.001). Communication regarding the updates was disseminated via e-mail to the entire organization, with fliers posted on all patient care units, and verbally during staff meetings. Patient equipment personnel manually tagged each pump with a blue zip tie after verifying the update to easily identify which pumps had been updated. Areas for improvement include increasing communication to the staff detailing when the update will occur and changing the day of the week the update is performed. CONCLUSION: A multidisciplinary team actively engaged in the updating of wireless i.v. smart pump drug libraries reduced the amount of time required to reach a goal adoption rate of 80%.