With high profile medication errors being discussed in the media (see this report by the LA Times on Quaid twins alleged heparin overdose at Cedars-Sinai Medical Center), the news comes out of C.S. Mott Children’s Hospital in the University of Michigan about a successful use of an enhanced photoemission spectroscopy device to monitor the safety of intravenous medications in the pediatric population. The device, used in the study just published in Am J Health-Syst Pharm, is called ValiMed™ Medication Validation System by ValiMed, a division of Tuscon, Ariz.,-based CDEX Inc.
From the press release issued by the University of Michigan:
A device designed to eliminate mistakes made while mixing compounds at a hospital pharmacy was 100 percent accurate in identifying the proper formulations of seven intravenous drugs.
Five potentially serious medication errors were averted over an 18-month period in a test at C.S. Mott Children’s Hospital in the University of Michigan Health System by using the technology, said Jim Stevenson, associate dean of Clinical Sciences at the U-M College of Pharmacy. Stevenson also directs Pharmacy Services at the U-M Health System.
Stevenson said the hospital is the first in the world to use this device to test patient drugs compounded in the pharmacy. The U-M Health System already has many safeguards, such as bar coding, in place to avert mistakes…
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, Stevenson said. However, the primary safeguard for intravenous drugs compounded in hospital pharmacies today remains a visual check by the pharmacist. Using a technology like this helps prevent mistakes that can occur due to human error, he said.
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 able to be integrated into the workflow of the pharmacy when used for select high risk products, the paper said. 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.
The device can also be used to monitor those naughty anesthesiologists (and other MDs, and RNs) that tend to inject themselves, rather than patients, returning normal saline and not quite normal morphine back to the pharmacy.
Press releases: Device prevents potential errors in children’s medications …; Improving Medication Safety: Independent 18 Month Study of ValiMed™ Medication Validation System by CDEX Published in American Journal of Health-System Pharmacists …
ValiMed Technology …