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One-on-One with David Troiano, R.Ph., Principal, CSC Corporation

May 15, 2009
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Troiano discusses how progress toward medication safety is still not fast-tracked.

It’s almost universally acknowledged — and backed up by statistics — that medication errors remain the largest category of medical errors overall. Yet moving the healthcare system forward toward the next level of medication safety is a step beset with challenges, as Julie Morrison, David Troiano, R.Ph., Jane Metzger, and David Classen, M.D., the authors of a new report from the Falls Church, Va.-based CSC Corporation found this spring. In their introduction to Moving Medication Safety to the Next Plateau, the CSC researchers found that, “Much of the progress so far has been achieved by reacting to external direction concerning safe practices and focusing on gaps that become apparent in the investigation of incidents.” Further, the authors say, “Getting to the next plateau will require continuing this work, but with a focus on the entire medication use process, rather than on piecemeal projects. Building upon the work so far, it will also involve extending standardization, incorporating safe practices to all key processes and patient care areas, and optimizing reliable workflows, reinforced by carefully-designed safeguards.” The intelligently applied use of clinical IT will obviously be critical to that effort.

David Troiano, R.Ph., who leads CSC’s medication safety practice, spoke recently with Senior Contributing Editor Mark Hagland regarding the findings of the report, and what needs to happen next. Below are excerpts from that interview.

Mark Hagland: It’s becoming clear that medication management really is an incredibly complex process, isn’t it?

David Troiano, R.Ph.: It certainly is, yes.

MH: Did you and your colleagues feel discouraged in completing this report?

DT: It was almost a reaction of surprise, really. It’s not that a lot of people aren’t making progress and working hard on this; but though there’s a lot of effort going on, there’s still a long way to go. For example, I started working recently with a hospital client; they’re a very sophisticated hospital. But they’ve made some mistakes—they decided they wanted to go with barcoded meds administration, but they neglected to understand how that process was integrated with dispensing, so they made some fairly unwise choices around how dispensing should take place, choices that introduced added inefficiencies into the system. They hadn’t understood this, but fortunately, someone from the organization called us before they had gone live. And hopefully, we’ll be able to work things out for them.

MH: It makes me think of the visual image of trying to organize a football stadium filled with people to hold up flash cards in just the right way for television cameras. It feels that complex.

DT: Yes, exactly, that’s a good metaphor. You start out saying, we’ll do this one thing in this one area, and then you realize that everything bumps into everything else. So, for example, you and your colleagues decide to work on ensuring that all medication use is safe; but to do so, you find you need to look into such diverse areas as med/surg floors, the ED, the OR, and so on. They’re all such different clinical environments, and yet your goal is trying to achieve standardization and compatibility of solutions, so that the people in the pharmacy can manage the overall process in some way that makes sense.

MH: And it seems that the medication order-set issue seems to be a complex and challenging one that is so often overlooked.

DT: Yes. And in many organizations, it really requires a multi-year initiative to achieve success in that area. The first step is simply coming up with that content, and getting the diverse physicians to agree that that’s the right content, and covering enough of the bases and giving them enough flexibility to deal with the outlier situations; that part of the work alone is a huge task that can take years to put in place. And second, there’s the transition from paper to electronic; that ends up requiring a whole different process. We’ve often had to go through two rounds of work with clients, in that regard. And how do we model choices, in terms of what is acceptable and not? And translating that into a system is a huge task unto itself.

MH: It has to be a multidisciplinary process involving medicine, nursing, pharmacy, and IS from the very beginning working together, don’t you agree?

DT: Yes, absolutely. And people tend to think far too narrowly; they’ll say, well, I just want to change this one little thing in pharmacy, but it ripples out. And whether you’re doing process redesign or system redesign, you have to have a multidisciplinary focus, or you’ll end up with something unsatisfactory for everyone.

MH: What are the pioneering organizations doing in this whole area, and what have been their critical success factors?