Build a Positive Safety Culture in your Pharmacy

A positive safety culture exists when individual and organizational decisions are driven by the shared goal of recognizing and reducing risk to prevent patient harm and when there is shared accountability for the outcomes. This results in optimized workflow, fair treatment of employees, and improved patient outcomes. This article highlights two inter-related cultures within the overall safety culture: a Just Culture and a Reporting Culture.

A Just Culture: Holding individuals and the system accountable

A Just culture acknowledges that errors occur in any system in which humans work and strives to treat employees fairly and respectfully. It holds the employee and the system accountable. Pharmacies with a Just culture will evaluate quality-related events (QREs) by looking at both human behaviors and system performance factors. A fair analysis will attribute the cause to: 1) simple human error, 2) risky behaviors, or 3) reckless behaviors. Human errors are primarily managed by consoling the employee. Risky behaviors are managed by coaching the employee to make safer choices and addresses the employee’s perception of risk of those behaviors. Reckless behaviors are knowingly harmful actions; primarily managed by discipline. System performance factors are also evaluated for their contribution to the quality-related event.

A Reporting Culture: Increasing the visibility of risk and harm

An effective reporting culture increases the visibility of risk and provides a safe place for employees to report medication errors, potential errors (i.e., good catches/near misses), unsafe conditions, and adverse reactions.

Informative reports alert managers to individual problems. Effective analysis and trending of reports helps managers identify the most significant problems. Reports using the reporter’s own words, are often rich with information that helps uncover the true causes of error and harm. A complete report will include a full description of the event; the degree of actual harm, immediate mitigation steps, and the ultimate outcome.

A Just Culture supports a Reporting Culture

A positive safety culture cannot exist if the workplace is perceived as unfair and unjust. Punishing human errors is demoralizing to the individual and to the team. Employees are less likely to report future events for fear of being blamed or to prevent a colleague from being punished. Managers become even more disconnected from the reality of risks and harms. Small risks can grow larger and small harms can become significant harms.

Intentional Leadership

Management strives to build a safety mindfulness, but must demonstrate through words, policy, and action that the collection and analysis of QREs are valued as opportunities to learn and improve the system.

Patient Safety Organizations (PSO)

A PSO can help you develop a positive safety culture. The Alliance for Patient Medication Safety (APMS) is a PSO that helps independent community pharmacies by providing 1) defined legal confidentiality protections for quality and safety programs, 2) strategies for improving the reporting culture, and 3) strategic ways to learn from QREs. PSOs help create a safe space to talk about and document continuous quality improvement plans. Pharmacies are not automatically granted these important protections until they join a PSO and participate in PSO-related activities.

Quality Assurance (QA) Meetings

It is management’s responsibility to regularly hold QA meetings within the safe space defined by the PSO to discuss reported risks and harms, lessons learned, and actions taken. Effective QA meetings will engage employees in a discussion of other probable causes, related concerns, and unreported concerns expanding the value of the individual QRE report or trend.

Summary

A Just culture, a Reporting Culture, and effective QA meetings are essential parts of the overall safety culture. The PSO adds further legal protections, providing a safe space to conduct all quality assurance activities. Importantly, pharmacies must join a PSO to enjoy these protections.

Promote a safety culture that is built on the principle of a "collective mindfulness” of the possibility of failure and encourage employees to speak out with their concerns. Evaluate your pharmacy’s culture with a self-assessment tool (below). Share with your pharmacy employees and see if you all agree.

• Your pharmacy’s safety culture accepts that mistakes will happen, but preventing harm is the primary goal
• Pharmacy employees feel confident in speaking up, regardless of hierarchy.
• Pharmacy employees are encouraged to report QREs when they happen, without fear of punishment.
• QA meetings are conducted under the umbrella of PSO protections and focus on the problem, not the people involved.
• When the pharmacy implements corrective action plans, they make sense, are shared with all employees, and follow the 3-part “sniff test”:
  • Does your workflow make it easy for each employee to make the safest choices and make it difficult to make unsafe choices?
  • Can everyone see a clear line of reasoning between the causal/contributing factors and the actions taken?
  • Is the corrective action plan monitored to assure it is working as intended or modified to better achieve its intended effects? More complex corrective action plans are piloted in a few locations before deploying across the company.

^{The mission of APMS® is to foster a culture of quality within the profession of pharmacy that promotes a continuous systems analysis to develop best practices that will reduce medication errors, improve medication use and enhance patient care. Pharmacies work with APMS® to look for inherent risks in the pharmacy’s workflow. Their program, Pharmacy Quality Commitment +TM (PQC+,) is an interactive CQI program that provides tools and resources for the pharmacy workforce to identify, report, and analyze quality-related patient safety events. APMS is a 501 c 3}