Frequently, and seemingly more frequently than in the past, notices are posted for recalled medications for various reasons. For example, recently at the end of December, select lots of single dose vials of lidocaine were recalled due to the presence of particulate matter, which may cause tissue trauma and inflammation when a patient undergoes MRI (see link: http://www.ashp.org/menu/News/PharmacyNews/NewsArticle.aspx?id=3998 for recall information).
Hospitals typically deal with hundreds of recalls per year, with some of those having potential patient impact and some extending to the level of patient notification. In hospital settings, pharmacies have developed numerous, although varied, methods of attempting to identify which patients may have received a recalled lot or which patients may be at risk of receiving a recalled lot but often, it feels a lot like a game of “Where’s Waldo”. Lots of time is spent reviewing inventory records, querying the pharmacy information system to determine who had an order for that type of medication, and then trying to determine which patients were more or less likely to have actually received that medication and that lot. Despite the evolution of bar-coded medication administration (BCMA) and electronic health records, there is still limited visibility into which lot numbers for a specific medications were delivered or administered to a specific patient.
In some cases, technology may be useful in identifying those patients. Some organizations have employed software for IV room workflow, such as IVTrac, that allow lot number capture, either by manually entering the number or through photo capture of the lot number, during the compounding process. When a medication lot number is recalled, technology can change the “Where’s Waldo” game and specifically target patients who had the recalled medication actually delivered. Eventually, industry-wide adoption of lot number enriched bar codes on all unit dose packages will standardize and improve the ability to capture lot numbers at the time of preparation as well, making this process even more efficient. Check out more on IVTrac and how our IV workflow solution can improve IV room operations.
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