Handle with Care

Cincinnati Children’s makes preventing errors in prescribing, preparing and giving medications a major priority.

Cincinnati Children’s Utilizes Technology and Collaboration to Keep Patients Safe When Prescribing and Giving Drugs

At 6 months old, Daylin is fascinated by the bright light coming from his nurse’s scanner. Little does he know, the scanner plays an important role in his care: to protect him from harm.

Before Daylin receives a medication, his nurse first scans the band that is securely wrapped around his leg. Then his nurse will scan a bar code on the medicine container to confirm Daylin is receiving the right drug.

“I trust Cincinnati Children’s with the care of my son,” says Brittany, Daylin’s mother. “The scanner is an important double check to make sure the medication isn’t mixed up and he gets the right dose.”

On an average day, the pharmacy at Cincinnati Children’s dispenses 7,000 doses of medicine for our hospitalized patients. This includes everything from over-the-counter ibuprofen to antibiotics to specially formulated chemotherapy drugs.

As a recognized leader in patient safety, Cincinnati Children’s makes preventing errors in prescribing, preparing and giving medications a major priority.

“Over the past several years, Cincinnati Children’s has implemented more than 45 medication safety measures,” says David Mayhaus, MS, PharmD, chief pharmacy director.

“Although we have made tremendous progress thanks to our innovative processes and information technology tools, there is no magic bullet when it comes to safety,” Dr. Mayhaus adds. “It is a constant battle we are ready and willing to fight.”

Eliminating Human Error

Cincinnati Children’s recently initiated a new process to ensure accuracy by eliminating the need for pharmacists to transcribe prescriptions. Now when ordering a drug, the patient’s physician types it into a computer system equipped with a customized software program that includes a complete record of the patient’s medications. Physicians, pharmacists and nurses all have access to the same record to check for any potential medication or dosing errors.

“Changing from handwritten prescriptions to computerized ones has made a huge difference in our ability to be more accurate and efficient,” Dr. Mayhaus says.

Before dispensing the drug, the pharmacists are prompted to review the entire medication profile for the child. In cases where they spot a potential complication, such as an allergy or risk of drug interaction, they consult with the physician about choosing alternative medications or adjusting the dose.

Building on Success

Last year, Cincinnati Children’s launched a new safety initiative in response to a newly identified threat: acute kidney injury caused by certain medications that can be toxic to the kidney.

The Nephrotoxic Injury Negated by Just-in-time Action (NephroNINJA) initiative utilizes a team of trained doctors, nurses and pharmacists who work together to track medications and alert caregivers when potential harm to the kidney from medication exists.

The effort began after Stuart Goldstein, MD, director of the Center for Acute Care Nephrology at Cincinnati Children’s, found that 86 percent of non-critically ill children at one large children’s hospital received at least one medication that was harmful to their kidneys during their hospital stay.

Many medications developed to improve the health of patients have also been found to be toxic to the kidney. Among the potentially harmful drugs are commonly prescribed antibiotics and anti-inflammatory medicines, as well as chemotherapy drugs. When these drugs break down, their waste products are deposited in the kidneys, making them vulnerable to injury.

It’s not unusual for patients to receive more than one nephrotoxic drug. If exposed to three, their risk of kidney injury doubles.

“What we’ve found is that up to one-third of our patients who are at risk due to these medications, do go on to develop acute kidney injury,” says Cynthia Barclay, PharmD.

As a Clinical Pharmacy Specialist, Dr. Barclay has helped to lead the initiative at Cincinnati Children’s. “It’s important to find and treat these patients early to decrease the risk of injury.”

First Line of Defense

Often, the injury to the kidney is not clearly visible. There may be no symptoms at the time, yet damage is done, leaving the child at greater risk for kidney disease in the future.

“No one thing makes acute kidney injury happen. Often, it occurs from chronic exposure to medications used with a variety of illnesses,” explains Catherine Krawczeski, MD, co-director, Center for Acute Care Nephrology.

To prevent exposure to harmful drugs, pharmacists on the NephroNINJA team use the electronic medical record system at Cincinnati Children’s to proactively look at medication orders for the entire patient population.

“Pharmacists are our first line of defense,” Dr. Goldstein explains. They screen a medication report every day, monitoring 40 specific drugs that are known to be toxic to the kidney.

When they see a child is about to be given a third nephrotoxic drug, they spring into action, consulting with the ordering physician to explore alternative treatment options.

Changing Care Standards Nationwide

Since the program began in June 2010, it has brought a tremendous amount of awareness to the issue of acute kidney injury. The collaborative approach, led by the NephroNINJA team, has been embraced by all of the medical and surgical service chiefs. They agree that this is an important part of our standard of care at Cincinnati Children’s.

“At this beginning stage of the initiative, the pharmacists are personally adding their knowledge and expertise each day, for each patient,” Dr. Goldstein says. “Once we’ve developed a validated approach backed by data, we would like to automate the system to remove the possibility of human error.”

The ultimate measure of success will be consistently predicting and preventing harm to our patients before it happens. Then we can share our knowledge to help more kids.

“We hope this program will serve as a best practice model and help more children nationally,” Dr. Krawczeski says.

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