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Pyxis Usergroup Meeting September 23-25, 2008 Case Study System Wide Bio-ID Failure.

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Presentation on theme: "Pyxis Usergroup Meeting September 23-25, 2008 Case Study System Wide Bio-ID Failure."— Presentation transcript:

1 Pyxis Usergroup Meeting September 23-25, 2008 Case Study System Wide Bio-ID Failure

2 Pyxis Usergroup Meeting September 23-25, 2008

3 Pyxis Usergroup Meeting September 23-25, 2008 Capital Health 1 Million pop 1.4 referral pop Northern Lights Peace Country Aspen East Centra l David Thompso n Calgary Pallise r Chinook Capital Health

4 Pyxis Usergroup Meeting September 23-25, 2008 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 Medicine Hat Red Deer

5 Pyxis Usergroup Meeting September 23-25, 2008 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)

6 Pyxis Usergroup Meeting September 23-25, 2008 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

7 Pyxis Usergroup Meeting September 23-25, 2008 Sites and SystemsSite Hospital Type Beds Drug Distribution Rx System GlenroseRehabilitation, Geriatrics 232Unit doseVAX Royal Alexandra Acute care / teaching 795Traditional, NN Sat, Pyxis, CIVA VAX University of Alberta Acute care / teaching 763Pyxis, Traditional, CIVA Cerner Millenium Alberta Hospital Psychiatric (Forsenic, Adult, Geriatric) 405Controlled dose cards, Traditional Cerner 3.06

8 Pyxis Usergroup Meeting September 23-25, 2008 Sites and SystemsSite Hospital Type Beds Drug Distribution Rx System Grey NunsCommunity360Unit dose, Pyxis, CIVA Cerner 3.06 MisericordiaCommunity313Unit dose, Pyxis, CIVA Cerner 3.06 Edmonton General Continuing Care 502Controlled dose card, limited CIVA Cerner 3.06 SturgeonCommunity152Unit dose, Pyxis, CIVA Cerner 3.06

9 Pyxis Usergroup Meeting September 23-25, 2008 Sites and SystemsSite Hospital Type Beds Drug Distribution Rx System LeducCommunity34Unit dose, Pyxis, CIVA Cerner 3.06 RedwaterCommunity14Pyxis, TraditionalCerner 3.06 WestviewCommunity 26Traditional, Pyxis, CIVA, Controlled dose cards Cerner 3.06 Devon (Westvie w) Community10Traditional, Pyxis (Nov 07) Cerner 3.06

10 Pyxis Usergroup Meeting September 23-25, 2008 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

11 Pyxis Usergroup Meeting September 23-25, 2008 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)

12 Pyxis Usergroup Meeting September 23-25, 2008 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

13 Pyxis Usergroup Meeting September 23-25, 2008 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”

14 Pyxis Usergroup Meeting September 23-25, 2008 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”

15 Pyxis Usergroup Meeting September 23-25, 2008 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

16 Pyxis Usergroup Meeting September 23-25, 2008 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

17 Pyxis Usergroup Meeting September 23-25, 2008 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

18 Pyxis Usergroup Meeting September 23-25, 2008 Process Changes Pyxis superusers require management approval and IS approval with Cardinal Health TSC support prior to performing any “Global edits”


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