Hospital uses high-tech system to check for errors

Every year, pharmacists at the University of Michigan's C.S. Mott Children's Hospital in Ann Arbor prepare a million doses of medicines for thousands of young and often very ill patients.

And because many of those medicines don't come in sizes or strengths for use in babies, children and teenagers, the pharmacists and technicians must mix many doses themselves. For some drugs, the smallest error in preparation can be a matter of life and death, so the pharmacy team takes special care to double-check every one.

Now they are using a new high tech addition to increase the level of safety to the mixing and dispensing of high-risk intravenous drugs like blood thinners and painkillers. But it's not a standard piece of pharmacy equipment. In fact, it started out in bomb detection.

The new team member is a 2-foot-long blue machine called the ValiMed system, which sits on the countertop in the Mott pharmacy. UM Pharmacy Services director Jim Stevenson, PharmD, explains that the machine flashes ultraviolet (UV) light into tiny samples of medicines, instantly checking their identity and concentration just before they're sent to a patient. The system is based on the fact that for most drugs a unique "fingerprint," called a fluorescence signature, can be detected when they are exposed to UV light, he says. Every drug's fingerprint is different.

The UM Health System is the first medical center in the world to use ValiMed for this purpose. The technology was first developed to detect explosives, and is being used at three other hospitals to verify that narcotic drugs aren't being diverted. In addition to watching for pharmacy errors, the system can help monitor for impaired physicians, drug theft, and counterfeit drugs.

Provides another level of safety

Stevenson says the ValiMed system, manufactured by the CDEV Co. in Rockville, MD, eliminates the small amount of potential for human error that remains even with a skilled, trained, and experienced pharmacy team.

"No matter what we humans do to check, double-check, and triple-check our work, there's still that chance for an error to slip through; and with children, especially, there's a lot of drug preparation and the risk to the patient from a medication error can be catastrophic," he says. "In this case, the technology can assure us that we're giving the patient the right drug, in the right concentration, just before it goes to the patient's room. It is the ultimate final check."

The system currently is in use at Mott Hospital, and another ValiMed system soon may be installed at the main University Hospital that treats adults. Stevenson says the machine is just the latest addition to an ongoing patient safety effort by the Mott pharmacy team.

In fact, the pharmacy staff has worked with ValiMed staff in recent months to set the standards that the machine uses to identify drugs. Every time it scans a 1 mL sample of a medication, the machine compares the sample's fluorescent "fingerprint" with a library of standard fingerprints in its memory. UM pharmacists worked with the manufacturers of ValiMed to create that library for high-risk medications, and performed pilot testing of the system before implementing it at Mott.

Can catch potentially harmful mistakes

The current reference library includes 10 commonly used intravenous drugs that need to be mixed specially for children and carry an especially high risk if they are delivered in the wrong concentration or to the wrong patient. Often, Stevenson says, pharmacists will make a batch of these drugs to dispense to many patients, using bulk medications and IV solution to dilute them so they can be delivered intravenously. Then, for each patient who needs the drug, the pharmacist will fill an IV bag or syringe for the nurse to administer. This means that if a mistake is made in creating the batch, many patients can suffer.

With ValiMed in place, the Mott pharmacists have incorporated a new step into their routine: they draw a tiny sample of the finished IV product, place it in a small square test tube that plugs into the top of the ValiMed machine, wait approximately 30 seconds, and read the machine's display. It tells them if the fluorescence fingerprint from the sample matches the fingerprint for the same drug and concentration from the library.

"We know that medication errors are already extremely rare at Mott, and anywhere at UM, but our goal is to not have any at all," Stevenson says.