News 01/07/2544

News 01/07/2544

MEDICATION ERRORS - THE ROLES OF PHARMACY EDUCATORS, PRACTITIONERS, AND STUDENTS IN MEDICATION ERROR REDUCTION: A CALL TO ACTION
Opportunities for students to advance the goals of medication safety and for practitioners and educators to mentor them in that role.

Medication Errors

The Roles of Pharmacy Educators, Practitioners, and Students in Medication Error Reduction: A Call to Action

Sharon Murphy Enright, M.B.A., R.Ph., Murfinc, Richmond, VA; Karen E. Smith, M.S., Pharmacy Practice Consultant, New Berlin, WI; Steven R. Abel, Pharm.D., FASHP, Department of Pharmacy Practice, Purdue University School of Pharmacy and Pharmacal Sciences, Indianapolis, IN; Amanda Clarke, Pharm.D., Drug Information Resident, Purdue University/Eli Lilly and Company, Indianapolis, IN

[Medscape Pharmacists, 2001. © 2001 Medscape, Inc.]

Introduction

It has been reported that nearly 400,000 deaths occur annually as a result of medical errors in the health system. Nearly 70% of those that occurred in hospitals were preventable.^[1] Shocking as that may be, further studies indicate that these estimates may in fact be too conservative. While studies conducted in the long-term care environment confirm the acute care pattern, little is known about error rates in ambulatory and community practice environments, where care elements are not clearly linked. It comes as no surprise that the landmark report from the Institute of Medicine, "To Err is Human: Building a Safer Health System," galvanized professional, political, and social forces to action.^[1]

While the rush is on to define solutions to the problem, it is troubling to note that most discussions of solutions center narrowly on specific aspects of the issue (eg, inadequate reporting) or on specific interventions that have not been implemented but have been known for years to be necessary to reduce certain types of errors. Little attention is dedicated, at other than a very global level, to the technologic and social complexity that defines a process prone to errors. Perhaps more importantly, educators of healthcare practitioners, including pharmacists, have not emphasized this critical issue during the educational process.

While it is comforting to recall that medication safety has always been a core value of healthcare organizations and professionals, particularly pharmacists, the reality is that talk and values-staking have comprised the vast scope of action, and all too often, individual practitioners have seen little personal opportunity to effect the safety balance. The complexity of the system, the lack of time for reflection, and the increasingly transactional nature of the work stifle innovation. As workload, acuity, and staffing shortages collide with flattened organizations, mentoring, collaboration, and dialogue give way to directives, quick fixes, and standup meetings whereby success is measured by elapsed time to a solution.

An interesting paradox exists at the core of the concerns. Like ostriches with heads buried in the sand, pharmacists at once deny the likelihood of error that exists in the increasingly complex healthcare delivery system, expecting "zero defect performance," and continue to operate as "captains of our own professional ships" in the care delivery process. No health professional -- physician, nurse, or pharmacist -- has the scope of control or information to absolutely prevent all medication errors. Yet we act as if we can, with growing fear that we may in fact "control" the next accident waiting to happen, but this action is rarely reflected through education. When errors do occur, the response is fairly typical in both practice and education: shame and blame, retrain, and/or reorganize. In the rapid jumping to solutions, we often sacrifice the reflection and understanding of system interrelationships that may have created the primary opportunity for error. That reflection and understanding is rarely evident in the pharmacy curriculum. Hence, the fix may be quite the wrong one, merely setting the stage for future errors.

Dealing effectively with errors demands change in the system, and as Albert Einstein once observed, "We should not try to solve problems with the same ideas that created them." Introspective analysis of individual and group performance, including planning and implementation of effective measurement systems designed to evaluate outcomes and results of care, cannot be viewed as a luxury; they are essential tools for success. Yet, where have we developed systems that meet the challenge, that look with fresh eyes and ideas at how this growing problem can be addressed?

Ensuring medication safety is a job for every caregiver, and one for which there is a significant role for practitioners, educators, and students. This article will highlight opportunities for students to contribute to advancing the goals of medication safety, and will provide a challenge to practitioners and educators responsible for preparing them and mentoring them in that role.

Errors and Medication Use

Errors are unintended acts of omission or commission that result in some failure to achieve an intended outcome.^[2] Medication errors can occur at many time points during the highly complex medication use process, from the point of prescribing all the way through the dispensing and administering process. The effectiveness and timeliness of monitoring can determine the impact on outcomes (Figure). Medication errors may or may not result in an adverse event with some injury to the patient.

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Figure 1.

Adverse drug reactions are considered unpreventable, whereas errors are clearly preventable. Just as important are near-misses, last-minute catches, and the looming potential errors that leave practitioners feeling like the trigger for the next accident waiting to happen.

There is no acceptable benchmark for error. Percentages of acceptable error are irrelevant if you are the patient or caregiver. Even a 99% safe system would produce 84 unsafe plane landings per day or 16,000 lost pieces of mail per hour, error rates that would hardly be acceptable to our society.^[3] Ford Motor Company learned this lesson painfully when it was determined that 84 people had died in accidents resulting from defective Firestone tires. A key quality executive commented that had she known of even a single death, all the data and quality reports in the world would have been insignificant.^[4] As individual caregivers, each person needs to assume personal responsibility and accountability for actively seeking out, identifying, and resolving potential sources of error, a first step in creating safety awareness and a culture to support it. And that rarely is the result of looking at data, safeguard systems, warnings, and procedures.

Combatting Error: Theory and Practice

Healthcare providers, including licensed providers, students, and educators, need education regarding the science and practice of error theory toward the goal of reducing error, improving safety and outcomes, and sustaining a safety culture. Fundamental is the concept that there must be a firm balance between commitment to a zero-error philosophy (knowing full well that the goal is unachievable) and a pragmatic realization of the delicate balance between risks and toxicities of medication use weighed against the potential benefits. Unfortunately, in organizations where there is an unwillingness to acknowledge that healthcare workers are human and make mistakes, the result is that errors are hidden or denied. More unfortunately, this is the norm, not the exception. Where the organizational focus continues to be on blame rather than prevention, the collaboration and openness needed for discovery, learning, and improvement cannot flourish.

Error theory tells us that errors are common, more so in complex systems. They are composed of slips and mistakes.^[2]

Slips often occur during implementation, when an individual knows what to do but does it poorly, wrong, or incompletely, often because he or she is distracted.
Mistakes involve errors of judgment in unfamiliar situations, such as decisions based on poor information or the use of rules and procedures that do not apply.

In relation to medication use, which is both complex and highly variable, it is virtually impossible to use simple rules and procedures. The result? The potential for slips and mistakes increases with the complexity of the medication use system, and it is virtually inherent in the process. Often the procedures and systems involved become so complex that latent errors become more likely. Latent error potential is typically outside the control of the individual, resulting from faulty system design, poor maintenance or management error, the proverbial accident waiting to happen.^[2] Latent or otherwise, the reaction to failure is more related to blame, sanctions, more complex protocols, new rules, new technology, reorganization, and fear reverberating through the culture. The greatest challenge may be in getting caregivers, administrators, and patients to realize that errors are typically system problems, not people problems.^[5]

Methods for Improvement

There is good news and bad news. The good news is that we have evidence-based literature that demonstrates clearly some of the solutions that contribute to safety improvement for medication use, identified over a 20-year period.^[6] The bad news is that little has been done to integrate that knowledge into consistent, day-to-day practices or the education of future practitioners. Without an infrastructure to force functions that highlight safety as a clear priority, an understanding of the interrelationship of systems and their components, and critical thinking skills to link the two, diffusion of this knowledge is random and inconsistent at best, and unlikely to be sustained.

Improvement of the medication use system to enhance patient safety demands change in the way we think and act -- transformational change that will stimulate breakthrough thinking and a focus on the results or outcomes of medication use. The people and the process need changing. Systems must be mapped and understood for what really happens, not what we believe to be common practice. Analysis should lead to logical and planned simplification, reduction of handoffs, minimization of transcription, use of standardized practice, and a dramatic reduction of the reliance on memory we now take for granted.

Constraints and forcing functions must be designed and implemented to support an infrastructure to drive behavioral change. Standards, guidelines, and protocols, based on evidence of best practice, must be developed and effectively implemented to drive change in practice. Computerization and automation must be considered and implemented strategically, with careful attention to optimization of the capability of the system to enhance medication safety. Embracing a philosophy of lifelong learning, beginning with the formal education process, will shift individual and organizational initiatives and goals toward competency-based, individually based learning plans, notwithstanding individual strengths and weaknesses. Communication skills, linkages, and effectiveness demand assessment and improvement since the literature is threaded with evidence that communication among caregiver teams may be among the most critical differentiators of outcome-related successes.

New knowledge, competencies, leadership skills, and the organizational elements to support an all-hands effort to improve safety transcends the task-force or project-based initiatives we have known to date. We must come to view defects as treasures, opportunities for enlightenment and discovery of better ways to practice.

This educational process must start early in the professional development of pharmacy practitioners and must be linked to a solid belief in the importance and power of lifelong learning. Both educational institutions and practitioner organizations must frame best practice and quality of care within a context of critical thinking for safe medication use.

The commitment to medication safety must be a common goal, spoken aloud and clearly reflecting job descriptions, policies, evaluations, management practices, and financial management of the department and organization at both strategic and tactical levels. A commitment to updated technology, understanding, and action will require the investment of time and money, and technical, process and behavioral training are critical. Ongoing evaluation of medication use system performance at the bedside and at the aggregate level must be a fundamental component of our day-to-day work.

A Role for Students in Medication Safety

Opportunities for student involvement in medication safety improvement are broad and significant; however, students will need to be well prepared for the task at hand. Currently, students, as well as practitioners who have come before to enter practice, need to gain an overall understanding of the medication error process and an appreciation for the opportunity for professional impact. Inherent to future success is an upgrading of skills in critical thinking, problem solving, communication, collaboration and dialogue, and process improvement.

Assuming a significant contributory role for medication safety for students presumes some significant preparation on the part of schools and educators. Goals for curricular change must focus on providing critical thinking skills, problem solving, data analysis, and collaborative communication skills. These skills further need to be grounded in a contextual understanding of today's healthcare system -- its dynamics, challenges, and pitfalls -- that goes far beyond pharmacy. Basic course work in the "science" of medication use improvement is a mere start. Throughout the curriculum, attention to framing medication use and safety discussions around quality, care delivery, and safety must be designed as carefully woven messages, supported by experiential evidence. Systems thinking and skills should be designed to support the critical link between pharmaceutical care and medication use improvement.^[7] The wisdom of error theory, complexity and chaos theory, learning from other industries, and the application of evidence-based medicine must be inculcated into the thought process of how to prepare practitioners for the challenges of the contemporary healthcare system.

Observation and documentation are critical to successful educational redesign, not a strong point in our current practice model. Within this objective, educators need to provide a safety net for students to learn in the context of basic standards that can be applied practically in their caregiver role. Fundamentally, based on a collaborative care model, this dialogue must be conducted in a nonthreatening manner. Students must learn to identify opportunities associated with the minimization of errors and the improvement of medication safety. They must also learn to document errors or other adverse events through preexisting systems such as FDA's MedWatch program.

In addition, educators and preceptors must create an expectation for students to be involved and to assume a leadership role. This will include engagement in required projects, interventions, and discussions; partnering students with practitioners to create learning incubators, and most importantly, providing access and insights to learning resources to support development of new and creative ideas.

A Collaborative Effort

Teamwork is key to the success of the critical collaborative dialogue that will lead to innovative improvement. Collaboration and bridge-building linkages between professional groups are not easily built, particularly on the foundations of a segmented educational process. Collaboration must be established and nurtured early in the curriculum. Physicians, nurses, and pharmacists must learn to work together with a clear understanding of common and differentiating issues and goals, forever with the patient as the common link. It is incumbent on educators to create standards and expectations that will foster student involvement in performance improvement and the noble goal of improving patient outcomes. The focus must be on results, not on the narrow focus of one's singular involvement in completing a task.

Require applied projects, including basics of peer to peer, practitioner to patient, and practitioner to administrator communication skills development, and structure opportunities for dialogue designed to reinforce fundamental learning objectives: focus on the patient, do the right thing, do it well, and continually improve the quality of care. Ensure that students understand the pivotal role of patients' involvement in the care decision process, and that they are skilled in patient interaction and interviewing.

Assessment skills and reporting as aspects of dialogue will be critical predictors of success. Learning and teaching through stories and experiences will define success in many situations. A planned strategy for transfer of these critical skills will be essential.

Competency will continue to be at the core of each organization's ability to deliver medication safety day after day. Students, as future practitioners, will need the framework and practical plan to execute a lifelong learning strategy intended for the continual skill building that takes a new employee from entry level to mentor, from novice to expert over time, with assurance of the judgment and critical thinking skills that form the necessary safety net. Schools will need to establish that baseline understanding of competency measurement and assessment of individualized performance improvement planning and its application to recruitment, retention, and advancement. Practitioners and leaders alike must understand the model for personal and organizational success and advancement.

Guidelines for Practitioners

Students enter practice with years of knowledge, baseline skills, and behavioral resources; hence, there is a need to transfer knowledge and experience between them and more experienced practitioners. Seek opportunities for use of skills-based assessment, dialogue, and active involvement of students in projects and ongoing departmental activities such as quality improvement initiatives. Look for ways to share experiences -- good and bad -- to facilitate that transfer of knowledge and best practice, and discuss traps, problems, and prevention strategies that have been successful or unsuccessful in the past.

Mentors must model multidisciplinary collaboration and involvement in cross-functional activities, allowing students to observe firsthand the power of communication among diverse professional care teams, with all focus on the patient and improving outcomes. We must create opportunities for students to observe and be involved with problem solving and the related communication wherever possible.

Incorporate new ways of thinking into current practice. The enthusiasm and new knowledge of students can be a springboard for incorporating new ideas and learning into practice, while fresh observations and data insights of students' "new view" may offer the innovation necessary for practice redesign. Keeping an open mind and remaining current with developments in safety theory, change management, and human factors will encourage piloting new ideas involving all staff members. Most importantly, look for and use learning opportunities in the day-to-day events of practice activity, and apply that learning for all staff members across the organization. Where possible, include focus on community and public health. Get beyond blaming and continually focus on the patient, doing the right thing and doing it well, with an eye toward improvement.

Guidelines for Students

Students bring a unique and usually unbiased view of the role of the pharmacist in the medication use process, but typically one focused more narrowly on the pharmacy perspective. They bring a wealth of new learning, new ideas, enthusiasm, and a delight in discovery. Often they are poised to serve as catalysts for change and improvement, and can fill the critical role of being the added resources to get a complex job done. Advance discussions and thought must be given as to how to identify opportunities for learning and involvement in experiential practice rotations. Learning opportunities abound with interaction between physicians, nurses, pharmacists, other caregivers, and patients. Be prepared to fill in the gaps for safe patient care. And always remember you are not alone as a student. We are all students in the arena of medication safety and improved outcomes, and we all have a lot to learn.

Use "fresh eyes and enthusiasm" to bring hope for the future. As students, you bring new ways of looking at old systems if you keep your focus on the patient and improved results of treatment. In the midst of rapid knowledge transfer and information gathering, maintain a close focus on safety in the care process. Beyond concentration on accumulating factual knowledge, work on skills for empathy, vision, compassion, and caring, seeing the patient as a person. Watch for opportunities to shadow practitioners who exhibit these caring traits and emulate that caring.

Concentrate on understanding the need for collaboration and bridge building. Learn and apply skills for teambuilding and open dialogue, applying them with pharmacy practice colleagues and students, as well as with other caregivers. Use every opportunity to generate discussion of problems, issues, and how the system really works to understand the perspectives of other practitioners, as well as to gain insight into where potential flaws in the system might predict errors.

Maintain focus on the continuum of care and the impact medication use has on overall health and system performance. Errors happen in the cracks of systems, where handoffs occur. Think about and watch for opportunities for pharmacists to play a role in assuring patients' improved quality of life or prevention of adverse outcomes.

Be aware, observe and understand the implications of caregiver actions and reactions in the care delivery process. Watch for opportunities to provide an extra check or balance in the system. Carefully note when errors or near-misses occur and document that event. Listen for questions that occur repeatedly, or the need for procedural clarifications of practice systems. Know that if a procedure is unclear to you and others, it may be a contributing factor to a future problem.

Conclusion

Medication safety is not a project, certainly not one with a distinct and simple solution in sight. It is a complex challenge in a chaotic system setting that will demand ongoing and vigorous attention for a long time. It is a classic opportunity to apply a cycle of quality improvement.

While new insights are needed, they cannot be delegated. We must all assume responsibility and accountability for encouraging system assessment, innovation, and contributions to improvement. New communication methods are essential as healthcare progresses, the pace accelerates, technology becomes more complex, and we face tough manpower issues. As the need to transfer information and knowledge across the continuum expands, new team concepts and structures, broader alliances -- including patients -- will be essential. We are in this together, as practitioners, but also as patients.

And remember: safety is not a destination. It's a journey.

References

Kohn LT, Corrigan JM, Donaldson MS, eds. To err is human. Building a safer health system. Committee on Quality of Health Care in America. Institute of Medicine. Washington, DC: Academy Press; 1999. Available at: http://bob.nap.edu/html/to_err_is_human/.
Reason J. Human Error. Cambridge, Mass: Cambridge Press; 1990.
Deming WE. Out of the crisis. Cambridge, Mass: Massachusetts Institute of Technology; 1986.
Berdish D. Learning and leading through the badlands. Presented at Managing Organizational Complexity Conference: Systems Thinking in Action; October 24, 2000; San Diego, California. 5. Leape LL, Bates DW, Cullen DJ, et al. Systems analysis of adverse drug events. JAMA. 1995;274:35-43.
Cohen MR, ed. Medication Errors. Washington, DC: American Pharmaceutical Association; 1999.
Hepler CD. Regulating for outcomes as a system response to the problem of drug-related morbidity. J Am Pharm Assoc. 2001;41:108-115.

Disclosure Statements:

Steven R. Abel, PharmD, has no significant financial interests to disclose.

Sharon Murphy Enright, RPh, has no significant financial interests to disclose.

Karen E. Smith, RPh, has no significant financial interests to disclose.

Amanda K. Clarke, PharmD, has no significant financial interests to disclose.