Today’s post is yet another edition of “Tales from the Counter.” This one is somewhat less clinical sciences and a bit more pharmaceutical sciences, with a measure of soapbox thrown in for good measure.
The other day, while performing CMM on a nursing care center patient being admitted, my technicians asked about a DUR Warning our pharmacy system flagged on the patient. These warnings are generated by software licensed from a third party vendor and are designed to bring possible issues to the attention of the pharmacist. The warning here read:
Prior Adverse Reaction Report
Prescribed Drug: Triamcinolone Nasal Spray
Adverse Reaction(s) have been reported with prior MORPHINE SULFATE 20 mg/ml.
Ethylenediamine Class Monograph
Essentially, the above warning is stating that the patient has had a prior adverse drug reaction (ADR) to morphine, and the newly prescribed drug (triamcinolone nasal spray) may also, therefore, cause problems with the patient.
I will let that sink in for a moment. Any pharmacists that immediately know why this was flagged are encouraged to comment below (giving yourselves a little pat on your own back), because this one is a little obscure (though there is a hint in the general description above).
The warning continues on as follows:
Discussion: Aminophylline is the ethylenediamine salt of theophylline. Hypersensitivity reactions to aminophylline including maculopapular rashes, dermatitis, exfoliative dermatitis and urticaria are thought to be primarily due to the ethylenediamine component…
Pharmacists who are still confused are thinking clinically and not pharmaceutically at this point. The ADR being flagged by the software is not due to either morphine or triamcinolone (in the nasal spray). The ADR being flagged is to an excipient (inert ingredient) that both products may share: EDTA (ethylenediamine tetra-acetic acid), which is a pharmaceutical chelating agent / preservative.
The science behind this Prior ADR Warning is sound and well documented in the primary literature, though the clinical relevance may be tenuous. The prevalence of EDTA in morphine injectable formulations is lower today, with many preservative free formulations available. Checking several references, ADR references to maculopapular rash with morphine were completely absent.
The Soapbox
In the end, it was easy to identify the prior ADR to morphine for this patient: confusion. Based on this, the triamcinolone nasal spray represented no additional risk for the patient, and the warning was documented off as a false positive. And while this computer-generated warning was not relevant for this patient, the obscure nature of the issue is not something that most pharmacists would immediately recognize and therefore it is entirely possible that a warning like this might help prevent patient discomfort in someone down the road.
Software-aided screenings can be very beneficial, but they also complicate patient care tremendously. It takes a skillful and knowledgable professional to be able to decipher and evaluate the host of information available today. Yet, pharmacy benefit managers continue to cut reimbursement for product and this is leading to pharmacies using fewer and fewer pharmacists (because labor costs are one of the largest expenditures in pharmacy). The argument is that technicians and machines can take care of more and more of the work. Without a competent pharmacist evaluating the mountain of clinical information, though, healthcare will be taking a step backwards in safety.
It is not unlike today’s aircraft: modern computer driven avionics can take a plane into the air, to the destination, and back down for a safe landing without any human intervention. But what happens when something out of the ordinary takes place,and the computer cannot make the judgement? Would you fly in a plane capable of flying itself without a professional pilot on board just in case? Modern technology can move pharmacy into a new era of efficiency in dispensing, but in the case of actual patient care, we are still a long way from not needing a professional in the trenches.