Pictures don't cut it for medication safety: ISMP

Hospital pharmacy leaders should be vigilant about eradicating the syringe drawback method —  and taking pictures during sterile compounding isn't enough, according to Rita Jew, PharmD, president of the Institute for Safe Medication Practices. 

The practice of the syringe drawback method, when a pharmacy worker draws air into a syringe to show a pharmacist what has been put in an IV bag, is dwindling. Children's hospitals are less likely to use the antiquated process, Dr. Jew said, but it's estimated that between 1% and 10% of the nation's hospitals still use this method.  

"You can imagine this is not the best way to validate the correct amount of drug has been put into the IV bag because the wrong amount can be put in, but the right drawback volume can be presented to the pharmacist," Dr. Jew said. "There's no way anybody who's doing the double checking can be sure this is the right amount of the drug that goes into the bag."

The ISMP has long advocated for the use of IV workflow management systems to automate the sterile compounding process. The tool scans ingredients' barcodes and requires pictures during the process, and some capture gravimetric data for extra assurance. 

Some are still using the syringe drawback method despite having the IV workflow system, though, which nullifies the technology's safety features.

"I would never even think that people would be doing the syringe drawback method when they're taking pictures," Dr. Jew said, "until we saw one and we started asking."

Hospital leaders have told Becker's that upgrading medication safety is a key priority — and CMS data shows why.

Between Jan. 1 and Sept. 29, 2023, CMS investigators cited hospitals more than 80 times for medication errors, according to the most recent data available. These reports included incorrect drug administrations and deliveries, storage issues, and improper handling of unusable drugs.

Recently, drug errors have led to immediate jeopardies at Main Line Health's Lankenau Medical Center in Wynnewood, Pa.; Los Angeles-based Northridge Hospital Medical Center; and Adventist Health Simi Valley (Calif.). 

The ISMP also recommends pharmacy leaders pay extra attention when introducing IV workflow systems and other new technologies.

"You want to go where the work is done and watch what's going on," Dr. Jew said. "That's especially important when you first implement technology. You want to make sure the workflow you devise is what people are using and there's no drift in your process."

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