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 the safe administration of medication for both patients and caregivers. 

The Beginnings of RxToolKit

Prior to founding RxToolKit, Chuck was a graduate of the Albany College of Pharmacy in Albany, New York. One day, he decided to join the United States Navy as a direct commission as a lieutenant and became a pharmacy officer. Many of the duties are the same as a hospital pharmacist and he got involved in infusion therapy while there. This was when infusion therapies by pharmacy were relatively new, though.

Subsequent to that, he left the Navy and became an executive of several large pharmacy organizations primarily devoted to institutional pharmacy, like Medicare. By then, he had spent about 15 years not practicing as a pharmacist and missed it, so he quit his job. After moving back to Pennsylvania, he began working at Reading Hospital and immediately became aware of the difficulties pharmacists had with keeping up with the different technology and content. 

He went to his boss one day and said, “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?” He felt like he could fix it.  

With a four inch binder, he filled it with content from about 40 pharmacists. Realizing there was a better way, he called John Neville, now the CIO of RxToolKit, to figure out how they could consolidate information into one place where people could search it and work off the same sheet of information. They then designed the beginnings of RxToolKit. After presenting it to Reading Hospital, RxToolKit was launched eight months later. 

A Near Miss: Emily Jerry & Eric Cropp

There was a story going around about a young two-year-old girl in Cleveland who died as a result of a medication error. Unfortunately, Chuck had a near miss himself, meaning when you have a medication error that doesn’t actually reach the patient. It was a very busy day and Chuck was checking IV’s. You have a timeline and lots of IV’s to check. After checking multiple IV’s and for whatever reason, he double checked it realizing it wasn’t right. It really scared him as it could’ve been a serious medication error. 

He began to research more about Eric Cropp and this little girl named Emily Jerry. Chuck found out that the pharmacist who made the error was in a similar situation as he was previously. The pharmacy computer system had been down, he had a timeline and a stressed environment where people were calling him for IV’s. A technician had run out of a normal saline, so she had planned to create her own. She used concentrated a diluted version. She ended up using a concentrated form of sodium chloride and never diluted it. Eric didn’t catch that error that the technician made and subsequently that drug was administered to Emily and Emily died as a result of that. Eric ended up going to jail. Chuck decided he really wanted to talk to him to understand his experience. Eric came to Reading Hospital, primarily to speak to the pharmacy staff. It turned out that when the hospital got wind of it, they actually opened the doors and he spoke to multiple disciplines. He actually made several presentations, and Eric’s story was very compelling. 

There are reports in literature of people going as far as committing suicide when they’ve made a catastrophic medication error. That put Chuck on the path to want to do something to help himself and his colleagues to prevent these errors from occurring. 

Protecting the Patient & Caregiver

After launching in June of 2004, RxToolKit was basically a catalog of content of procedure manual and some drug information, but also how it was used, so Chuck began separating it 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 how he could assist in doing this. This was the switch from content provider to a resource. We built over 22 different applications and one was standarizing this neonatal intensive care. 

Today, we have had two saves that we’re aware of. A physician was woken up at three o’clock in the morning, was asked to prescribe an infusion concentration for a baby and made a multiple fold error. The pharmacist who checked it put it through RxToolKit and it recognized the error. The pharmacist called the supervisor on call and they confirmed it by logging into RxToolKit and doing the same thing, preventing that error from happening or ever reaching the patient. 

Another situation was when dealing with NICU infants. The dosing has to be extremely precise with them. We built a tool where we took every drug in the entire crash cart and we allowed the user to put the patient’s weight in and maintain that. The policy is 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. We used a kit for a drug called Adenosine. The kit was stocked incorrectly and as a result, the NICU nurse, when presented with the dose that she was to be administered based on the sheet, looked at the kit and noticed that the concentration wasn’t the same as what the sheet said. This red flag allowed her to get another kit and administered the correct amount.

Cheers Award

Each year about 3 or 4 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

One day out of the blue, RxToolKit got a call from Bryan Johnson. Previously, Chuck developed a whole labeling and packaging system for hospitals. In 2017, Bryan said, “I’ve seen some of your labels online and I’d like to learn more about them.” That was our introduction to the 

WeInfuse team. Over the years, we never had a formal relationship in terms of a business relationship, but we always consulted one another. We started to grow in the infusion center market with a lot of referrals from the WeInfuse folks and talking to nurses at hospitals that needed help. 

We got to meet them at the NICA Conference in Austin in 2019. RxToolKit was always really comfortable with the team. One day their COO, Reece, called me up and said, “You know what? We think we might be able to do something together.” My wife and I always said if there were a company that we would ever want to partner with, it would have been WeInfuse. Our philosophies about business were aligned. Our approach to customer satisfaction and customer service were aligned and our innovation to think out of the box and do things differently were aligned. It was an easy decision. RxToolKit went down to their office in 2022 and Chuck was very excited surrounded by the youthful exuberance and creative minds that surrounded him.

Parting Advice

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, don’t ever push them underground. It’s the only way people will learn best practices is to learn from the errors and constantly reevaluate your process and include the people that are doing it. 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.