Introduction

Errors related to pharmacy preparation of sterile injectable products and admixtures continue to be reported to the Institute for Safe Medication Practices (ISMP). A 2009 State of Pharmacy Compounding Survey showed that 30% of hospitals experienced a patient event involving a compounding error within the prior five years.¹ In response, ISMP published “Guidelines for Safe Preparation of Compounded Sterile Preparations” with best practice recommendations in 2013. These guidelines were revised in 2016 (Figure 1).2 Since many of the errors “repeatedly show that the manual inspection of IV admixture ingredients by pharmacy technicians and pharmacists is not a totally effective deterrent in preventing preparation and dispensing errors,” the guidelines call for “organizations to have a strategic plan for implementation of automation and technology for sterile compounding” that “augments manual processes for preparing and verifying” compounded sterile products (CSPs). Moreover, ISMP specifically advocates for technology “systems that include barcode scanning verification of ingredients, gravimetric verification of drug and diluent volumes, and/or robotic image recognition” and goes on to further delineate that “at a minimum both barcoding and gravimetrics are used…. [when] preparing chemotherapy and ideally, for pediatric CSPs.”²

To raise awareness and gauge adoption of these best-practice recommendations, ISMP recently surveyed 634 pharmacy practitioners (80% pharmacists, 18% pharmacy technicians) who prepare or oversee the preparation of CSPs. Results of this survey were published in the October 22, 2020 edition of ISMP’s Medication Safety Alert newsletter.³

Survey Results: Implementation of ISMP best practices

Participants gave input into nine questions for whether they “always,” “often,” “sometimes” or “rarely” follow best practices (Table 1). Aside from the best practice recommendation for ensuring sufficient workspace inside the IV room (“always” rating of 73%), the other eight questions fared much worse, with “always” compliant ratings ranging from 34% to 56%. A summary of some startling findings include:

• Standard operating procedures are “always” followed just 56% of the time.
• Staff can “always” identify with certainty the drugs & diluents used during a preparation only 52% of the time.
• Dose volume information (to eliminate reliance on manual calculation) was “always” readily available only 49% of the time.

Challenges with adopting ISMP best practices

Survey respondents also ranked their biggest challenges with meeting the ISMP guidelines. As shown in Table 2, the top challenges cited were (1) lack of direct observation, (2) difficulty meeting USP<797> standards, (3) insufficient staff competency and training, and (4) insufficient technology, followed by a general theme of workload (staffing), time, efficiency and interruptions.

Top 10 ways IVWMS technology can support ISMP best practices

Wondering how technology can help support these critical compounding best practices? Here are the top 10 ways technology can help address some of the challenges:

1. With standardization comes reduction in variability—a fundamental tenet of patient safety and high reliability.^4,5,6 IVWMS aims to ensure all staff follow the same process for each CSP every time.
2. Eliminate the need for proxy methods of ingredient verification (e.g., syringe pull-back method) with remote verification enabled with image capture.
3. Remote verification also enables sharing of workload to more pharmacists without reliance on being physically near the IV room.⁷*
4. Remote verification reduces consumption of expensive personal protective equipment (PPE) and the labor (time) it takes to put it on and take it off before entering and after leaving the IV room where verification is typically done.⁷*

   *The University of North Carolina Medical Center (UNCMC) showed how utilizing remote pharmacist verification for CSPs lead to increased efficiency in pharmacist time plus lower PPE consumption that equated to an annualized cost savings of $23,770 (7).

5. Eliminate reliance on potentially risky manual calculations thanks to software enabled gravimetric algorithms that automate calculations.
6. Gravimetric verification improves dose accuracy with a scale that makes errors (volumes outside preset tolerance levels) apparent to everyone and can stop them from being released. Dose accuracy is no longer limited by human performance.⁸
7. Gravimetric verification with hard stops can help users correct errors before they are committed. In addition to the safety benefits, this also helps avoid the expense of having to waste and remake an erroneous dose.
8. Barcode scanning and image capture ensures that each ingredient is correct. With the addition of gravimetrics, certainty that the volume was indeed transferred to the receiving container can be demonstrated.
9. Integrated task management software improves the likelihood that standard operating procedures aimed to maintain United States Pharmacopeia (USP) and board of pharmacy compliance are consistently followed. Before routine tasks (e.g., cleaning, environmental monitoring, competency, etc.) come due, on-screen reminders help remind users to complete the task. When tasks are overdue (representing noncompliance risk), administrators have options to employ hard-stops to ensure a compliant compounding state is never compromised.
10. Compounding errors (as a result of comingling or intermingling ingredients) can be reduced with barcode scanning and also by using a bin and a bin label to keep things separate during the workflow. IVWMS can support a labeled bin workflow by guiding the user to gather all the necessary parts (e.g., ingredients, supplies) for a single CSP.

References