Thursday, June 27, 2013

It's Time to Begin

When I was a little kid, I was always asked the question, “So what do you want to be when you grow up?” I would answer emphatically, “That’s easy- a journalist.”

Why? I have always found the profession to be quite fascinating. The work that it entails- researching and writing to deliver a news story to be shared with an audience of readers, listeners, and viewers- is right up my alley. Even as a kid, I enjoyed reading and writing and engaging an audience with a good story. Through the past decades, several individuals have emerged as prominent leaders in the world of journalism, and I aspired to be just like them. It amazed me how they were able to ask the right questions when it came to “getting the real dirt” on a story, and even after the delivery, I would be left to wonder more about it. 

Then I got a little older, and I began to understand and realize the amount of passion and hard work that went into the profession and to me, it seemed to be a tough industry to break into. At around the same time, I discovered my love for science, particularly chemistry, and with that, I decided to pursue a career along that track. I chose pharmacy, and how I got there is another story for another day.

Fast forward more than 10 years to 2011, at which point I have graduated with my Pharm.D., and I am setting out to begin my pharmacy career as a PGY-1 pharmacy resident. I was excited and when I first started out, I had plans of pursing a PGY-2 specialty residency in critical care and eventually becoming a specialist in critical care pharmacotherapy.

By chance, I had to make a minor adjustment in my schedule of rotations, and it was requested for me to have my emergency medicine (EM) elective rotation in October instead of February. I was agreeable to this change, and so October rolled around and I started my five-week rotation in the emergency department. I selected EM as an elective because I thought that it would be a pretty decent experience, even though I was informed that not many residents pick EM as an elective because of the blood and guts, fast pace, and somewhat high-stress environment of the emergency department (ED). I was ready for a challenge, and I figured that even if I did not like it, I knew that it would come to an end in five weeks’ time. And so I began and spent the first week of my rotation with our evening shift EM pharmacist. 

And I soon realized that I was wrong…very wrong. About my career plans, that is. 

What happened? I fell hard in love with the ED. 

For me, EM encompassed everything that I was interested in learning more about, from critical care to ambulatory care to infectious diseases to everything else in between, and applying that knowledge directly to the acute care of patients. I was able to appreciate the contributions that I could make as a pharmacist in the emergency department, and I felt that my work was valued. 

Simply put, I saw my work come to life. Anyone who practices in the ED knows what I mean and can definitely corroborate this statement. 

Even though EM was previously nowhere on my radar, I knew that by the third week of the rotation, I was going to have to change gears and pursue a career as an EM pharmacist. However, a five-week rotation in the ED was not enough, and I applied for and later accepted the position for the PGY-2 specialty residency in EM at the same institution. 

During my first week of residency, my program director sent me links to a number of EM and toxicology websites and blogs to follow, as the content found on these sites would help guide my way during the first couple of months of the residency. These websites and blogs proved to be critical to my training for the entire year. 

In my third month of the residency, my program director started this blog, which I thought was pretty neat, since it put a different spin on the websites and blogs that I was already following, as the goal was to provide an outlook of things related to EM from the perspective of the pharmacist. I was invited to write about the role of the pharmacist in the emergency department for a blog post after an interesting discussion. I wrote it, and I instantly became hooked. Finally, after many years, I was able to hone my interest in writing in such a way that held true to my original aspirations of becoming a journalist and was still related to my experiences in the emergency department. 

After a few weeks, I became a regular contributor to this blog and I simultaneously started a Twitter account to share my residency experiences and pearls that I have gained along the way. One by one, I began interacting with EM physicians, pharmacists, students, and other practitioners from all over the country and world that I never imagined to be possible. Through Twitter, I learned about FOAMed, and with the sharing of knowledge through this medium, I was able to enhance my own learning throughout the residency. I cannot even begin to fathom my residency experience without FOAMed. In addition, FOAMed has also inspired me to write about a number of topics on this blog, and I have had a number of requests through both Twitter and from clinicians at my hospital for topics to be written about as well. Researching and writing about these topics has not only provided me with a mechanism to sharpen my writing skills, but it has also supplemented my learning experiences. And just to sweeten the deal, I have been able to meet some of my Twitter “peeps” in person at conferences, which has been pretty amazing. 

Fast forward a few more months, and the day has inevitably arrived- that is, my final day as a resident. I have worked with awesome EM attending physicians and residents this past year and my residency program director, preceptors, and mentors have facilitated my training with plenty of guidance and support along the way, for which I am truly thankful. I am grateful for the educational opportunities I have been afforded throughout my residency and the connections I have made with members of the FOAMed community through Twitter. FOAMed has encouraged me to ensure that I am up to date with the latest in EM, which I hope to maintain as I begin my transition from EM pharmacy resident to an “attending EM pharmacist”, as some have put it. No worries- I am not going too far, and I will certainly continue to post my EM pharmacy-related musings on this blog. 

There have been some whisperings that have turned into discussions on Twitter and other blogs regarding the educational impact of FOAMed and the recognition of FOAMed outlets as scholarly activity, and ways in which we can allow for this to come to fruition. I anticipate that this will become a worldwide community effort, and I am excited and curious to see how this will unfold.

It’s time to begin.

Thursday, June 20, 2013

Do Drug Shortages Beget Medication Errors?

Drug shortages have plagued our practice for quite some time now. It is difficult to keep up with what is or is not currently available, even with the availability of a number of websites from various professional groups dedicated to inform us of them. It seems as though literally every day, another medication suddenly vanishes from the market with an unknown release date from a number of manufacturers.


It goes without saying that drug shortages have certainly impacted patient care as we scramble to find reasonable and viable alternative medications for those on shortage to produce the same effects we wish to achieve. We have been hit pretty hard in the emergency department, as a number of classes of medications have been on shortage, which has certainly impacted our practice over the past few months. For instance, the availability of medications for cardiopulmonary resuscitation has seems to have gone on rotation with shortages in epinephrine, sodium bicarbonate, dopamine, dextrose, just to name a few. In addition, when considering broad spectrum antimicrobial coverage for our patients, aminoglycosides and fluoroquinolones seem to make an appearance one week, only to be on shortage the following week. For patients requiring sedation and analgesia, it seems that we have a "sedative of the week", as propofol and a number of benzodiazepines and opioid analgesics have also been shoddy in supply from week to week.

An interesting question can be posed from all of this. Do drug shortages lead to a greater incidence of medication errors?

Now, you may be thinking to yourself, "Well, how can it? If the product is on shortage, then errors associated with the medication are unlikely."

A number of points have to be considered regarding this question:
  • Lack of familiarity with the dosing of alternative medications due to lack of utility in practice
  • Differences in packaging of medications (for example, with D50 bristojets on shortage, one may resort to the 25-mL vials of D50, which some practitioners may not be familiar with)
  • Rotating stock of various concentrations of medications that are packaged similarly (for example, substituting hydromorphone 2 mg/mL in the automated dispensing cabinet for hydromorphone 1 mg/mL)
  • Substitution for alternative medications in which the packaging may be similar to medications of different classes that are already available
  • Utilizing concentrations of medications that may be different from the products that are on shortage that practitioners may not be as familiar in terms of adjustments in the rate and units required for infusion

So what do we do about this?

Essentially, it all comes down to communication, communication, and...communication.

It is not enough to be informed that a product is on shortage and when the expected amount of time in which the product will be unavailable for. Information regarding alternative therapies that are available needs to be communicated to practitioners. In addition, extra vigilance should be exercised by the staff involved in the administration of alternative therapies to ensure that the appropriate medication, dose, and/or infusion rate is being delivered to the patient. This document provides an excellent step-by-step process on implementing alternative therapies in the setting of a drug shortage. Medication errors that do occur should be reported to the Institution for Safe Medication Practices (ISMP) in order to enhance the awareness of practitioners regarding such errors in order to prevent them from happening in the future.

Selected references:
Institute for Safe Medication Practices. A shortage of everything except errors: harm associated with drug shortage. ISMP Med Saf Alert [online] 2012; 17:1-3.
Institute for Safe Medication Practices. Drug shortages: national survey reveals
high level of frustration, low level of safety. ISMP Med Saf Alert [online] 2010; 15:1-6.

Ventola CL. The drug shortage crisis in the United States: causes, impact, and management strategies. P T 2011; 36:740-757.

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