“Focus is needed in many walks of life, but for patient safety

it is needed every day. Every pharmacy across the country is always one day

closer to dispensing a fatal dose of medication.” - Jeff Hedges

Over time people can become complacent - creating the perfect environment for an accident to occur. Pharmacists can fill hundreds of prescriptions a week, and in order to meet the demands of pharmacy life, they may overlook small steps and have a misfill occur. To prevent your pharmacy from complacency, use the two C's: control and communication.

CONTROL

To help improve patient safety and reduce misfills, everyone in the pharmacy must be involved in quality control.  Identifying missteps and errors, and being aware of sound-alike/look-alike drug fills are ways to ensure you are taking proactive measures.

Types of Errors

Quality Control Errors: found behind the counter

Medication Errors/Incident: any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patients, or consumer

Adverse Drug Reaction: any unintended effect on the body as a result of the use of therapeutic drugs, drugs of abuse, or the interaction of two or more pharmacologically active agents

Errors are inevitable, so it is essential to know what you need to protect yourself, as well as your patients. The Patient Safety and Quality Improvement Act (Patient Safety Act) requires that a Continuous Quality Improvement (CQI) Program be implemented.

Continuous Quality Improvement Programs

 A CQI program is designed for detecting, documenting, analyzing, and preventing Quality-Related Events (QREs), with the intent of preventing medication errors. A CQI program creates an environment that makes quality the top priority, and allows pharmacy staff to learn from past mistakes.  A proper CQI program will:

• Designate an individual or individuals to be responsible for monitoring CQI program compliance
• Identify and document QREs
• Minimize the impact of QREs on patients
• Analyze data collected in response to QREs to evaluate causes and discover contributing factors
• Incorporate findings to formulate an appropriate response and develop a corrective action plan
• Provide ongoing education, at least annually, on CQI related to pharmacy personnel systems and workflow processes designed to prevent QREs.

Pharmacies must recognize that problems exist — problems that unavoidably cause mistakes to happen. These are system problems; to change the outcome and prevent the same error from occurring in the future, we must change the system.

COMMUNICATION

Pharmacy staff must be willing and open when discussing all failures of quality. Reporting errors should not lead to blame or punishment, but instead need to be seen as an opportunity to learn and improve. When an error occurs, your first question should be, “What in our system allowed this error to occur?”

To start improving your quality of care, a few simple questions can help open the dialog with staff.

Do you:

• Discuss medication errors and near misses that occur in your pharmacy? 
• Evaluate your workflow and look for areas for improvement?
• Know which errors occur most often in your practice? 
• Meet to discuss ways to implement new processes to prevent errors in the future? 

Traditionally, there has been resistance to open discussion and disclosure of patient safety events. Legitimate concerns over potential legal and financial liability would arise. To encourage a safe environment for discussion, patient safety organizations (PSOs) were created.

Patient Safety Organizations

PSOs serve as independent, external experts that can assist providers in developing insights on effective methods to improve quality and safety. If you work with a PSO and work within the policies and procedures that they help you establish the patient safety work as a whole is considered protected and privileged.

BENEFITS OF PSO's

1. PSOs can make a positive impact on the pharmacy operation — providing feedback, recommendations, and support processes of root cause analysis

2. PSOs assist you in designing your Patient Safety Evaluation System (PSES)  

PSES: a system of policies and procedures for collecting, managing, and analyzing information for reporting to the PSO

3. PSO provides the framework for safety data to be protected as a patient safety work product (PSWP)

PSWP: any quality data and analysis and/or oral statement assembled or developed by a provider for reporting to a PSO and that constitutes the deliberation or analysis of a PSES

There are currently 84 PSOs supporting all healthcare providers, but only five are listed as focusing on pharmacy, and they are:

• Alliance for Patient Medication Safety
• Institute for Safe Medication Practices
• The Patient Safety Research Foundation
• The PSO Advisory
• Quantros Patient Safety Center

Each PSO offers different services and contract fees. You need to find the best solution for your operation. Check with your PSAO, as they may already have a relationship with a PSO.

A PSO provides far more than just a framework to participate in a CQI program in a protected environment. Think about how much time and effort is spent identifying an error, reversing the prescription, re-dispensing the correct prescription, and making multiple contacts with the patient; leading to loss of revenue. When pharmacists and staff start realizing the amount of time and money that are lost, the importance of reducing medication errors takes on a new meaning.

In a team-oriented environment, where safety is the priority, the staff can review breakdowns in the workflow processes and achieve the goals of increased patient safety. If your pharmacy utilizes Control and Communication, efficiency is improved and misfills are reduced, resulting in better quality of care for patients.

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About the Author

R. Jeffrey Hedges is President & CEO of R. J. Hedges & Associates.  He is a board-certified DME Specialist (CDME) and serves on the Board of Directors for the Board of Certification/Accreditation (BOC) . To read Jeff's full article on the Patient Safety Act that was published in Computer Talk magazine click here!

About Us

R.J. Hedges & Associates provides compliance and accreditation experts that will help guide you and your pharmacy to unlock it's fullest potential! We have helped hundreds of independent pharmacies and facilities stay compliant, pass audits, inspections and easily earn Medicare accreditation. Visit our website at http://www.rjhedges.com/ to learn more about what we do!