by Sheri Herner, PharmD, MHSA, CPPS, BCPS, FCCP
Chair of BPS Pharmacotherapy Specialty Council
Medication Safety and Quality Coordinator
Kaiser Permanente Colorado
Patient Safety Awareness Week™ is March 14 – 20, 2021. The objective of the event is to promote understanding about health care safety and to “inspire action to improve the safety of the health care system.” The Institute for Healthcare Improvement (IHI) is asking you to take the Pledge for Safety this year.
There are threats to patient safety arising every day, so safety professionals regularly scan the environment to identify new risks. Medication safety risks can stem from everyday occurrences, like technology changes, staffing pattern shifts, operational priorities competing with safety, and drug shortages and recalls, or uncommon events, like global pandemics leading to new vaccines and therapeutics, for which additional safety monitoring is required.
Pharmacist role in medication safety
As a Board Certified Pharmacotherapy Specialist working in a medication safety and quality role, I am positioned to improve patient safety by supporting the healthcare team on patient safety initiatives. As a medication safety expert, I assist with investigations to discover how errors happened. Having clinical expertise and experience in the health care system makes it possible for me to see how and why an event unfolded. I may collaborate with the health care team to develop a clinical plan to take care of a patient who experienced an error that caused harm. When system or process weaknesses in the medication use system are identified through voluntary error reports, I can collaborate across disciplines to strengthen error reduction strategies in the health system. A top priority of medication safety professionals is to make it easier to do the right thing. Another regular activity is to analyze and share safety data, including voluntarily reported error and adverse drug reaction reports and more objective process and outcome metrics.
You can and do make a difference every day
Medication safety is a specific area of focus within the discipline of patient safety that pharmacists are uniquely positioned to influence. Even though many health care organizations employ medication safety experts who lead and manage medication safety strategies and plans, nearly every health care professional can improve medication safety.
Most pharmacists can recall times when they identified and intervened on a safety-related drug problem, and those actions are impactful and rewarding. Pharmacists sometimes don’t recognize these scenarios as errors because they view their resolution as performing their usual professional duties to solve drug related problems, such drug-drug interactions, inappropriate dosing, and contraindicated medications. There may be weaknesses in the medication use system that allowed those scenarios to transpire.
Pharmacists, like other health care professionals, are skilled at working around system and process failures to complete their work. When pharmacists correct an error and omit reporting it or investigating why it happened, they may be adopting the “fix it and forget it” approach to problem solving, which allows the hazard to perpetuate. By taking additional steps to discover if there are contributing factors within existing systems or processes that could be ameliorated, patient outcomes can be improved for many individuals in the future.
What can you do to prevent future patient harm?
Pharmacists can prioritize safety by:
- proactively identifying risky situations or practices
- reporting errors, including near misses, so the health care system can learn from those incidents
- speaking up when unsafe circumstances exist