pyxis usergroup meeting september 23-25, 2008 case study system wide bio-id failure

Pyxis Usergroup Meeting

September 23-25, 2008

Case Study

System Wide Bio-ID Failure



Capital Health

• Capital Health• 1 Million pop• 1.4 referral pop

NorthernLights

PeaceCountry

Aspen

East Centra

lDavid

Thompson

CalgaryPallise

r

Chinook

CapitalHealth

YellowheadCounty (East)

Edmonton

SturgeonCounty

StrathconaCounty

Leduc County

Parkland County

Ft Sask

Stony Plain

St Albert

DevonLeduc

Redwater



Capital Health

• Large academic health region– 25% from out of region

• $2.6B operating budget

• 30,000 staff

• Alberta’s most complex patients

• 2,400 physicians

• 3,000 hospital beds (13 hospitals)

• 6,500 community care beds

• 10,000 home care clients/mo

• 635,000 calls/yr Capital Health Link– 200,000 out of region

• 9M sq ft of space

• 4,200 health students

• $120 M in research funding

• 8 Primary Care Networks

MedicineHat

Red Deer



Capital Health

• 13 hospitals– 3,000 beds (acute care, psychiatric, rehabilitation)

• Community Care Services, e.g., home care (10,000 clients/mo)

• 37 Long Term Care Centres/20 operators under standardized contract

(CMI based)

• Specialized Long Term Care programs:– C.H.O.I.C.E.

– Subacute Care/Palliative Care

• 22 public health centres / 4 specialty clinics

• Community Mental Health Services (8 clinics)

• Primary Care Initiatives

– 8 Primary Care Networks (50% of physicians)

– Northeast Community Health Centre

– Health First Strathcona

– Eastwood Primary Health Centre (under development)



Service Volumes

Annual Service Volumes• 635,000 calls for health advice (Capital Health Link)• 1.8M clinic visits• 435,600 emergency visits• 969,000 patient days in hospitals• 114,400 inpatient discharges• 92,970 surgeries (48,662 day surgeries)• 13,902 births • 450,000 immunizations• 10,000 home care clients/month• 40,025 environmental health inspections

*2005/06



Sites and Systems

SiteSite Hospital TypeHospital Type BedsBeds Drug Distribution Drug Distribution Rx SystemRx System

Glenrose Rehabilitation, Geriatrics

232 Unit dose VAX

Royal Alexandra

Acute care / teaching

795 Traditional,

NN Sat, Pyxis, CIVA

VAX

University of Alberta

Acute care / teaching

763 Pyxis,

Traditional, CIVA

Cerner Millenium

Alberta Hospital

Psychiatric (Forsenic,

Adult, Geriatric)

405 Controlled dose cards,

Traditional

Cerner 3.06



Sites and Systems

SiteSite Hospital Hospital TypeType

BedsBeds Drug Distribution Drug Distribution

Rx SystemRx System

Grey Nuns Community 360 Unit dose, Pyxis, CIVA

Cerner 3.06

Misericordia Community 313 Unit dose, Pyxis, CIVA

Cerner 3.06

Edmonton General

Continuing Care

502 Controlled dose card, limited CIVA

Cerner 3.06

Sturgeon Community 152 Unit dose, Pyxis, CIVA

Cerner 3.06



Sites and Systems

SiteSite Hospital TypeHospital Type BedsBeds Drug Distribution Drug Distribution

Rx Rx SystemSystem

Leduc Community 34 Unit dose, Pyxis, CIVA

Cerner 3.06

Redwater Community 14 Pyxis, Traditional Cerner 3.06

Westview Community 26 Traditional, Pyxis, CIVA,

Controlled dose cards

Cerner 3.06

Devon

(Westview)

Community 10 Traditional, Pyxis

(Nov 07)

Cerner 3.06



Clinical Information Systems Project• Pyxis implement throughout hospital including and

Pyxis profiling• Cerner Millenium computer system and use of Pyxis

Connect • Unit dose medication packaging• New orders checked to original• Cerner Millenium MARs in inpatient units• Updated med admin processes / renovations to med

rooms• IV and non-sterile compounding workcards• PAR X, and C2 safe• Policies and procedures• Contingency and Failover



Background:

• University of Alberta/Stollery has about 700 acute care beds

• Affected 40 Patient Care Units including ER and OR/PARR

• 51 MedStations• About 3800 Users

(3500 use Bio-ID)



History

• Implementation of Pyxis Medstation on 35 new units (to add to the existing 8 units)

• Implement on the majority of care units involved incorporation of Cubie technology

• Several of the existing Pyxis medstation care units required a name change AND a change in the Medstation design to cubie technology



Impact of using “Global edit”• The existing users had access to the

original Medstation name, but no access to the revised medstation name, therefore all users needed to be converted such that they could access the medstation under the revised name

• It was the impression of the Pyxis superuser that this change could be accomplished by performing a “Global edit”



Impact of using “Global edit”• The intent of the superuser was to exclude

the users from having access to the original care unit name but to gain access to the revised care unit name

• Instead, the result of using the “Global edit” was that now ALL users had complete access to ALL medstations in the facility

• This was discovered by the superuser who made the “Global edit”



Impact of using “Global edit”• The superuser discovered her error by

reviewing a user profile after the edit, and realized that the user had “all area” access

• The superuser then called the Cardinal Health TSC line to request that her edit be reversed



Impact of using “Global edit”• The edit was successfully reversed, but all

Bio-ID access failed for all users and all users needed to revert back to password in order to reset their Biometrics

• Majority of the users no longer remembered their password



Resolution to problem

• All user passwords needed to be reset and communicated to each user in order for them to be able to set up their Biometrics

• The biggest challenge were the users that worked in the float pool



Process Changes

• Pyxis superusers require management approval and IS approval with Cardinal Health TSC support prior to performing any “Global edits”

pyxis usergroup meeting september 23-25, 2008 case study system wide bio-id failure

Documents

pyxis usergroup meeting

community care beds

beds acute care

health students

traditional cerner

home care clientsmonth

limited civa cerner

hospital beds