Enhancing Medication Safety – For Patients and Caregivers with RxToolKit
Chuck DiTrapano, RxToolKit Founder & VP of Pharm Ed, joined us on the podcast to offer insight on creating systems to enhance medication safety for both patients and caregivers.
The Background of Chuck DiTrapano
Before founding RxToolKit and dedicating his life to medication safety, Chuck graduated from the Albany College of Pharmacy in Albany, New York. Following graduation, he joined the United States Navy as a lieutenant and pharmacy officer, and then got involved in infusion therapy after finding similarities between a pharmacy officer and hospital pharmacist.
Subsequent to that, he left the Navy and became an executive of several large pharmacy organizations primarily devoted to institutional pharmacy, like Medicare. After about 15 years away from practicing as a pharmacist, he quit his job. Moving back to Pennsylvania, he began working at the Reading Hospital and immediately became aware of the difficulties pharmacists had with keeping up with the different technology and content.
A Near Miss: Emily Jerry & Eric Cropp
While on the job, Chuck faced a near miss medication error. It was a very busy day, and Chuck faced a hectic timeline and lots of IV’s to check. After checking multiple IV’s, he double checked one of them and realized it wasn’t right.
After having this near miss, he researched about Eric Cropp and a little girl named Emily Jerry who had died as a result of a medication error in Cleveland, OH. Chuck related to Eric, the on-duty pharmacist who was deemed responsible for the incident, and his story. The pharmacy computer system had been down, he faced a timeline, and a stressful environment. While preparing Emily’s dosage, the on-duty technician ran out of normal saline, so she created her own. She ended up using a concentrated form of sodium chloride and never diluted it. Eric didn’t catch the technician’s error before the drug was administered to Emily, causing her death and Eric’s time in jail.
When Eric got out of jail, he went around to speak about his compelling story that later inspired Chuck to do something to help himself and his colleagues to prevent these errors from occurring again. Similar to Eric, Chuck wanted to make good out of this type of situation.
The Beginnings of RxToolKit
He went to his boss one day and asked two questions that would further spark his RxToolKit mission:
- How do you know what people are doing?
- How do you know that pharmacist A is making the same clinical decision as pharmacist B when it’s relevant to a certain patient condition?
Using a four inch binder, he filled it with content from about 40 pharmacists and set out to fix these issues. He partnered with John Neville, now the CIO of RxToolKit, to figure out how they could consolidate information into one sheet of information. They then designed the beginnings of RxToolKit, presented it to the Reading Hospital, and launched RxToolKit eight months later in June of 2004.
RxToolKit’s first design was merely a catalog of procedure manuals, drug information, and how they were used. Chuck later separated the catalog into various care settings. The Joint Commission on Accreditation of Hospitals put out a standard that said that pediatric and NICU IVs had to be standardized, so the hospital asked if he could assist in doing this. This switched RxToolKit from a content provider to a resource. Over 22 different applications were soon built, and one specifically standardized neonatal intensive care.
Protecting the Patient & Caregiver: RxToolKit’s Impact so Far
Today, RxToolKit has had two saves that we’re aware of.
The first incident: A physician was woken up at three o’clock in the morning to prescribe an infusion concentration for a baby and made a multiple fold error in the process. The on-duty pharmacist checked the prescription and recognized the error using RxToolKit, and called the supervisor on call to confirm the mistake. Using RxToolKit helped prevent the error from happening or ever reaching the patient.
The second situation: When dealing with NICU infants, the dosing has to be extremely precise with them and has a strict policy. The document has to be on the cart so that if that baby does crash, all the doses are calculated, including right down to the milliliter and volume. RxToolKit takes every drug in the entire crash cart and allows the user to put the patient’s weight in and maintain that.
In the near miss incident, a kit for a drug called Adenosine was used and stocked incorrectly. The NICU nurse, when presented with the dose that she was to administer according to the sheet, looked at the kit and noticed that the concentration didn’t match the sheet information. This red flag allowed her to get another kit and administer the correct amount.
Cheers Award
Each year about three or four awards are awarded by the Institute for Safe Medication Practices, a nationally recognized resource for medication safety practices. In 2004, Chuck and John won the award for technological innovation. Chuck still has it in his office today.
Partnership with WeInfuse
Randomly, Chuck received a call from Bryan Johnson, Co-Founder and CEO of WeInfuse, asking about RxToolKit’s labeling and packaging system for hospitals. Over the years, RxToolKit grew in the infusion center market with referrals from the WeInfuse folks, consulting, and talking to nurses at hospitals that needed help.
The RxToolKit and WeInfuse teams met again at the 2019 NICA Conference in Austin. One day, Reece Norris, Co-Founder and COO of WeInfuse, mentioned partnering with Chuck and the RxToolKit team. Both company’s philosophies about business, approach to customer satisfaction & customer service, and innovation to think outside the box and do things differently were aligned. It was an easy decision. Chuck was very excited surrounded by the youthful exuberance and creative minds that surrounded him. RxToolKit officially partnered with WeInfuse in 2022.
Parting Advice: A Note from Chuck
When it comes to medication safety, you have got to know the drug and how it’s used in your clinical practice setting. Don’t assume anything. There’s a reason why pilots have checklists. Don’t ever make the assumption that you’ve got this without just refreshing yourself. Learn from your mistakes, learn from the errors, learn from the near misses, and don’t ever push them underground. The only way people will learn best practices is to learn from the errors and constantly reevaluate their process. I’ve always believed that people that are at the front lines really have the best information in terms of how to find where the pitfalls are. Those are the things that I’ve always tried to implement in my career.
Next Steps
Request a DEMO today from either WeInfuse (click here) or RxToolKit (click here) to learn more about our two services.
