Treatsie

I feel it necessary to comment on the current state of the 5900 satellite and express my concern over the issues of workflow and staffing.

When the BMT service moved to the north campus the initial pharmacist staffing was as follows: 3 RPh 0700-1200, 4 RPh 1200-1500, 3 RPh 1500-1700 and 2 RPh 1700-2200. While the BMT service as well as Med Onc have continued to expand, the number of pharmacists responsible for these areas is down, and now stands at 1 or 2 for the entire day with the exception of approximately 1-1.5hr from 1200-1400 when there is an overlap of a third pharmacist. By way of contrast, the clinical pharmacy staff responsible for these areas has increased from 1 to 5 with a 6th position already in the budget. Recently, the opening of 24/7 oncology center has added approximately 8-10 oncology patients to the daily chemotherapy count. The nature of an out-patient infusion center dictates these infusions are prepared on a STAT basis. Compass chemotherapy entry and verification has placed additional constraints on total preparation time. Also, not to be discounted in importance, is the loss of 1 of the 2 day shift IVRM technicians to the 13 CAM pharmacy.

Staffing of the area was one of the main highlighted issues during the Risk Management root cause analysis of the chemotherapy preparation sentinel event of about four years ago. As noted above we are currently working with 1/3 -1/2 of the staff we had at that time. Another outcome of those meetings was a follow up with other similar institutions to compare policies on staffing. To my knowledge, nothing ever came of these contacts because none of these institutions was doing anything comparable to the 5900 sat IVRM, with its combination of chemotherapy floors, ICU's, surgery and out-patient areas at the volume and staffing that we have.

The RIE of last year left the satellite with a totally inadequate filling/checking area. The current procedure of checking bins full of different patients’ chemotherapy amid the myriad of distractions in the satellite is increasing unworkable and potentially dangerous with regard to patient safety. In my opinion, this is the major flaw of the original workflow design and a contributing factor, if not the main reason for the most recent and probably most chemotherapy errors. If underlying causes of errors are in fact system breakdowns and not errors of individuals, then what we are experiencing fits that definition exactly. A system, suspect from the beginning, no longer workable.

All chemotherapy and IV admixtures should be checked by an IVRM pharmacist BEFORE IT LEAVES THE IVRM. The staffing of the IVRM by a single unsupervised technician has always been less than ideal. Our current staff of technicians are of varying experience and competency, the former not necessarily indicative of the latter.

Any chemotherapy safety RIE could address these core problems only marginally. For example the recent directive to assign responsibility by designating chemotherapy checking to a specific pharmacist at a specific time is unrealistic in the context of a staff of only 1 or 2 pharmacists. Any additional guidelines to assign responsibility without control only serve to sidestep the real issues and make the current process more cumbersome with negligible positive effect.

The addition of 1 pharmacist FTE would be a major first step. I would suggest a Mon-Fri 8-hour evening 1500-2300 shift. This would allow the shift time of the 1000-2000 7on/7off pharmacist to be changed to a start time of 0830. This position becomes the IVRM pharmacist, working and checking in the IVRM until 1900. This obviously adds morning help to the 0600 pharmacist, who currently works alone until 1000. The 1900 shift end time is late enough to have the majority of the evening scheduled chemotherapy completed. I would also foresee this position to do the majority of the chemotherapy verification in addition to helping the clinical staff enter orders when necessary. The new 1500 8hr position coincides with the end of the 0600 day shift, as well as help later into the evening/night shift when home medication sheet entry/checking has become an increasing problem in addition to the usual late chemotherapy new order starts.

I realize adding additional FTE's can be problematic. At this point I don't believe any procedural changes can make enough of a difference to solve our current problems. Steps need to be taken to prevent further chemotherapy errors. I hope that this can be accomplished in lieu of discussing a problem I've outlined here at a post error root cause analysis meeting.

Respectfully,