Cdex, Inc. (fka CDEX)

[capnmike]

Drug Errors No Stranger to Pediatric Units of Hospitals
Published: April 08, 2008

http://www.medpagetoday.com/PublicHealthPolicy/PublicHealth/tb/9043

Adverse "Drug-Events" Harms U.S. Children
April 8, 2008

Chicago, IL (AHN) - A new study published in the April issue of Pediatrics reveals that more and more children are at risk because of mix-ups in medications particularly those in hospitals.

The study says that about 7 per cent of children being hospitalized in U.S. were getting wrong drugs, accidental overdoses and unfavorable reactions.

http://www.allheadlinenews.com/articles/7010572204

In my opinion, an important University of Michigan Study...

First Generation ValiMed, published in Am J Health-Syst Pharm—Vol 65 Jan 1, 2008. Practice Report - Photoemission spectroscopy

http://www.ns.umich.edu/htdocs/releases/print.php?htdocs/releases/plainstory.php?id=6255&html=

http://www.ncbi.nlm.nih.gov/pubmed/18159039

http://www.ajhp.org/cgi/content/abstract/65/1/49

Improving Medication Safety: Independent 18 Month Study of ValiMed™ Medication Validation System by CDEX Published in American Journal of Health-System Pharmacists
ValiMed™ detected five potentially serious medication errors while consistently validating the correct medication solutions during an 18 month study at a major University Hospital.

http://www.cdex-inc.com/pr/10708.html

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The courageousness and professionalism of the University of Michigan team cannot be understated in my opinion. Clearly, they understand the importance of CDEX technology applications, and exhibit extraordinary professional bravery in publishing this stunning study.

Thank you Dr. James G. Stevenson, University of Michigan, John F. Mitchell, Pharm.D., Joshua Loveland, Pharm.D., and the pharmacists and technicians of C. S. Mott Children’s Hospital, Yaman Kaakeh, Hanna Phan, Brian D. DeSmet, Deborah A. Pasko, Denise K. Glenn, as well as Darrell Campbell, M.D., Mark Pearlman, M.D., and Chris Dickinson, M.D. who were recognized in this publication for their support of medication-safety initiatives. And thank you to our CDEX team.

I am convinced the efforts of the Univ of Michigan, as those of our CDEX team, will continue improving the world in this significant manner during my lifetime.
Mike
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2008 American Journal of Health-System Pharmacy, Vol. 65, Issue 1, 49-54 Practice Report - Enhanced photoemission spectroscopy for verification of high-risk i.v. medications

The full report is available for $25 online. Excerpts I found interesting...

A tabletop instrument (ValiMed, CDEX, Inc.) was used to validate high-risk i.v. medications that are commonly compounded in the pharmacy and used as bulk products for additional compounding into patient-specific doses.
. . .

During the 18 months since the technology was implemented, five potentially serious medication errors have been detected and avoided. Two of the incidents involved bulk vancomycin solutions that were compounded with only half of the required amount of vancomycin. The device did not validate the samples, and the pharmacist retraced the compounding steps. In another incident, an incorrect amount of morphine was used to compound the final product, resulting in a concentration that was three times higher than intended. Another potential overdose was detected in the fourth incident, in which 10 mL of lorazepam 2 mg/mL was added to 20 mL of 0.9% sodium chloride injection instead of 0.5 mL of lorazepam 2 mg/mL. The fifth error involved a mixup of dopamine and dobutamine.

Several nonvalidations were initially observed with lorazepam. After investigation, it was noted that these products were being prepared correctly but that, because of lorazepam's high viscosity, the drug was not evenly dispersed in the final product, resulting in what appeared to be an incorrect concentration. Thoroughly mixing the admixtures helped to avoid false nonvalidations. Awareness of this variation has improved the consistency of compounding practice.
. . .
In our pediatric hospital we currently test 40–50 samples of patient specific high-risk products each day. Staff support and training were provided throughout the trial, and the program has been well received.
. . .
Conclusion

A tabletop EPS device demonstrated acceptable sensitivity and specificity for validating the identity and concentrations of selected high-risk i.v. medications compounded for pediatric patients. The device may help prevent clinically important medication errors caused by inaccurate compounding.

http://www.ajhp.org/cgi/search?sortspec=relevance&author1=&fulltext=ValiMed&pubdate_year=&volume=&firstpage=


http://www.ajhp.org/cgi/content/abstract/65/1/49?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=ValiMed&searchid=1&FIRSTINDEX=0&sortspec=relevance&resourcetype=HWCIT

American Journal of Health-System Pharmacy, Vol. 65, Issue 1, 49-54
Copyright © 2008. American Society of Health-System Pharmacists, Inc. All rights reserved. 1079-2082/04/0602-1242$06.00
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Practice Report

Enhanced photoemission spectroscopy for verification of high-risk i.v. medications
Yaman Kaakeh, Hanna Phan, Brian D. DeSmet, Deborah A. Pasko, Denise K. Glenn and James G. Stevenson

YAMAN KAAKEH, PHARM.D., BCPS, is Clinical Assistant Professor of Pharmacy Practice, Purdue University, West Lafayette, IN; at the time of this study she was Pharmacy Practice Resident, Department of Pharmacy Services, University of Michigan Health System (UMHS), Ann Arbor. HANNA PHAN, PHARM.D., is Pediatric Pharmacotherapy Fellow, College of Pharmacy, The Ohio State University, Columbus; at the time of this study she was Neonatal Intensive Care Unit Clinical/Staff Pharmacist, Department of Pharmacy Services, C. S. Mott Children’s Hospital, UMHS. BRIAN D. DESMET, PHARM.D., M.S., is Pharmacy Specialist, Henry Ford Hospital, Detroit, MI; at the time of this study he was Pharmacoeconomics and Outcomes Fellow, Department of Pharmacy Services, UMHS. DEBORAH A. PASKO, PHARM.D., is Adjunct Clinical Assistant Professor, College of Pharmacy; Clinical Coordinator, C. S. Mott Pharmacy; and Clinical Pharmacy Specialist, Pediatric Critical Care, UMHS. DENISE K. GLENN, B.S.PHARM., is Supervisor, C. S. Mott Pharmacy, Department of Pharmacy Services, UMHS. JAMES G. STEVENSON, PHARM.D., FASHP, is Director of Pharmacy Services, University of Michigan Hospitals and Health Centers, and Professor and Associate Dean for Clinical Sciences, College of Pharmacy, University of Michigan, Ann Arbor.

Address correspondence to Dr. Stevenson at the Department of Pharmacy Services, UH B2D301, Box 0008, University of Michigan Health System, 1500 E. Medical Center Drive, Ann Arbor, MI 48109-5008

Purpose. The sensitivity and specificity of enhanced photoemission spectroscopy (EPS) for performing an automated final check of compounded i.v. admixtures at a pediatric hospital pharmacy were studied.

Methods. A tabletop EPS device was used to test samples of seven high-risk drug–diluent combinations compounded in the pharmacy; the drugs were vancomycin, lorazepam, morphine, insulin, hydromorphone, gentamicin, and epinephrine. Ten sets of samples were prepared for each drug. Typically, a sample set consisted of dilutions ranging from 10-fold above to 10-fold below the targeted concentration. Testing was performed twice weekly between November 2005 and March 2006.

Results. The EPS device detected errors departing from the targeted concentration by 20% or more with a sensitivity of at least 95%. Specificity in distinguishing among test medications at targeted concentrations was 100%. The percentage of passing samples with intermediate concentrations varied among the drugs.

Conclusion. A tabletop EPS device demonstrated acceptable sensitivity and specificity for validating the identity and concentrations of selected high-risk i.v. medications compounded for pediatric patients. The device may help prevent clinically important medication errors caused by inaccurate compounding.

Copyright © 2008 by the American Society of Health-System Pharmacists.

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Univ of Michigan’s Dr. James G. Stevenson and ValiMed on WEBMD

http://www.webmd.com/video/hospital-errors-medications

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University of Michigan Health System – US News & World Report HONOR ROLL
America’s Best Hospitals 2007

Honor Roll
U.S. News put 5,462 medical centers through progressively finer screens to create the 16 specialties rankings in the 2007 edition of America's Best Hospitals. Just 173 hospitals made it into the rankings, and of those, a mere 18 displayed the marked breadth of expertise, with high scores in at least six specialties, that qualified them for the Honor Roll. They are ordered by total points—a hospital got 2 points if it ranked at or close to the top in a specialties and 1 point if it ranked slightly lower (View 2007 Methodology).

University of Michigan Hospitals and Health Centers, Ann Arbor
9 points in 7 specialties

http://health.usnews.com/usnews/health/best-hospitals/honorroll.htm

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http://www.valimed.com/clients.htm