Valimed

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U-M Health System is first in world to use new light-based system to check high-risk medicines

University of Michigan
Pharmacists can verify drug identity & concentration to protect patient safety
July 5, 2005:

ANN ARBOR, MI - Every year, pharmacists at the University of Michigan’s C.S. Mott Children’s Hospital 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, their team has a new member who adds one more level of safety to the mixing and dispensing of high-risk intravenous drugs like blood thinners and painkillers. But it’s not a person. And it started its career not in a pharmacy, but in bomb detection.

In fact, the new team member is a two-foot-long blue machine called the ValiMed system, which sits on the countertop in the Mott pharmacy. It flashes ultraviolet 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 ultraviolet (UV) light. Every drug’s fingerprint is different.

The Mott pharmacy team has already added the ValiMed system to their process for preparing 10 commonly used and high-risk drugs.

The U-M 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.

U-M Pharmacy Services Director Jim Stevenson, Pharm.D., says the ValiMed system 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,” says Stevenson. “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 is currently in use at Mott Hospital, and another ValiMed system may soon be installed at the main University Hospital that treats adults.

Stevenson and his pharmacy teams have devoted tremendous time and effort to patient safety in recent years, as part of the U-M Health System’s overall push to prevent errors and near-misses, to learn from experience and to ensure high-quality care.

The ValiMed system fits well into that effort, using technology to make absolutely sure that high-risk medications are prepared correctly.

When exposed to ultraviolet (UV) light, every drug has its own characteristic "fingerprint". The ValiMed system checks drug samples against a library of stored fingerprints, acting as a foolproof check before medicines are given to patients.

In fact, the U-M pharmacy team has worked with ValiMed staff in recent months to set the standards that the machine uses to identify drugs. Every time it scans a one-milliliter sample of a medication, the machine compares the sample’s fluorescence “fingerprint” with a library of standard fingerprints in its memory. U-M 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.

The current reference library includes ten 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.

They include insulin, used to bring down blood sugar; heparin, used to thin blood; epinephrine, used to support blood pressure and cardiac function; narcotics such as morphine that reduce pain; and antibiotics such as vancomycin that can tame infections but can also be toxic if an incorrect dose is given.

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.

The Mott team plans to develop more drugs in the ValiMed reference library, and to perfect the process for using the machine as part of their routine procedure. Other possible future uses include validating the identity and dose of chemotherapy drugs used in cancer patients.

“We know that medication errors are already extremely rare at Mott, and anywhere at U-M, but our goal is to not have any at all,” says Stevenson. “This system will give us, and our patients and their parents, a little more peace of mind that we’re doing all we can to prevent errors. This is part of our mission to be a leader in medication and patient safety.”

Stevenson credits Darrell Campbell, M.D., chief of staff for the U-M Hospitals & Health Centers, and others in the U-M Office of Clinical Affairs, for providing initial funding for the system. He also notes the role of Mott Pharmacy supervisor Denise Glenn, BS Pharm., Clinical Coordinator Deborah Pasko, Pharm.D., and pharmacist Hanna Phan, Pharm.D., for their role in implementing the system.

Written by Kara Gavin

Source:
http://www.med.umich.edu/opm/newspage/2005/mottpharm.htm