Patient safety standards: An opportunity to shine
Medication error education, reporting are key areas
New patient safety standards give pharmacists the opportunity to step up to the plate and shine. "Given the way the patient safety standards are written, there is a tremendous opportunity for pharmacy to contribute in a very meaningful way to help an institution meet their intent," says William Ellis, RPh, MA, executive director of the American Pharmaceutical Association (APhA) Foundation in Washington, DC.
The standards were adopted by the Joint Commission on Accreditation of Healthcare Organizations and went into effect July 1. These standards are comprehensive and reflect some of the most "progressive thinking" about medication safety that is in line with the Institute of Medicine’s recommendations, Ellis says.
The standards don’t specifically address pharmacists, although Joint Commission President Dennis S. O’Leary in a June 28 conference call said that most of the standards apply to them. The Joint Commission often is not specific regarding the roles of any given profession within the hospital, Ellis notes. "There is not necessarily a discrete chapter on nursing standards or physician standards. A lot of the standards are outcomes-based."
By not focusing on roles, the Joint Commission tries to leave latitude to the institution to identify those individuals who are best suited for carrying out the patient safety standards, Ellis says.
The standards, however, do go into detail about how to set up a patient safety program, says Matt Grissinger, RPh, safe medication management fellow of the Institute for Safe Medication Practices (ISMP) in Huntingdon Valley, PA. "[They talk about] having qualified individuals and what should be included in the program."
The standards require institutions to be proactive in implementing quality-improvement programs, and pharmacists are well-positioned to assist in this effort, Ellis says. "Obviously patient safety cuts across a whole spectrum of care," he says. "But because medications are such an important part of the hospital care that patients receive, there are any number of quality improvements in which pharmacy would be in a great position to help establish."
These quality improvements would help the institution meet the intent of the standard, he continues. Some of the quality improvements might include monitoring adverse drug events, identifying and monitoring patient drug allergies, and identifying and monitoring food and drug interactions. "These are all examples of patient safety issues that pharmacy and pharmacists around the country have done for many years. There is a lot of information in the literature that talks about the role of the pharmacist in identifying and resolving drug-related problems."
Three areas of focus
Pharmacists can look at three main areas where they can help their institutions address the Joint Commission’s patient safety standards, Grissinger says. They include:
• Patient education.
According to the standards, "specific attention is directed at educating patients and families about their role in helping to facilitate the safe delivery of care." In addition, the standards hold patients responsible for asking questions when they do not understand what they have been told about their care or what they are expected to do. "We have seen so many errors in which patients never questioned what [medications] they were getting," Grissinger says. "They don’t know what they are supposed to get or why they are getting it."
Patients need to be educated about the role they have to play in the safety process, he adds. "Patients are the last step in medication administration. If they are not told or encouraged to be part of this process and to speak up when they think something is wrong, then errors will continue to get through to them."
Obviously, pharmacists can’t educate every patient in the hospital about his or her medication. But they can actively promote and become involved in the patient education process. They also might focus their education attention on patients with certain high-alert medications, Coumadin being one example, Grissinger says.
• Physician and staff education.
Pharmacists should teach other pharmacists, nurses, and staff in the hospital about medication safety, Grissinger says. "Give them situations where errors have occurred, not just in your hospital, but in other hospitals. Educate them about why the errors happened."
Pharmacists, for example, can provide information about the problem of misuse of abbreviations, Ellis says. "U for units for insulin has been confused for many years (the U looks like a 0), and the errors have led to serious injury and death," he says. "There can be programs to eliminate the use of dangerous abbreviations." The education process also can include providing information about potential problems. "Pharmacy can certainly help educate other health care professionals during a new employee orientation program about error-prone aspects of certain drugs," Ellis says.
Physicians and staff could be educated in ways to reduce errors when newly approved medications are ordered, too, Grissinger says. "When a new medication comes out, errors occur many times because a doctor orders it, and no one knows anything about it." Pharmacists rush to order and dispense the drug, getting it to the floor on time. Then they find out later it is the wrong drug, he says.
• Error reporting.
Get pharmacists and the whole organization more actively involved in reporting near misses, even ones that happen in the pharmacy, Grissinger says. "Sometimes pharmacists take orders over the phone that they think might be wrong. We call to clarify the order. We get the right order written and then dispense the drug. We don’t do anything about why the order was wrong in the first place."
Ask staff to report errors both internally and externally to organizations such as ISMP, so they can educate others about the errors, he says. "Pharmacists can take an active role in error reporting by telling people what can happen so they can convince the people to report the same things to them."
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