HOSPITAL PRACTICE

Medication safety officer:
A new breed of pharmacist

In the United States, up to 7,000 patients die annually from medication errors, but as many as 40% of these errors could be prevented. Those statistics, according to Steven Rough, M.S., R.Ph., director of the pharmacy service organization at the University of Wisconsin Hospital and Clinics, are the reason he is actively looking to recruit a pharmacist to fill a new position, that of medication safety officer.

Rough said, "Errors are usually fueled by faulty 'system' design. Our goal is to improve 'systems' to prevent future errors." Pharmacists are a crucial link in the medication-use process, so it makes sense to utilize them to oversee all aspects related to safety and quality assurance in hospitals.

According to Kasey Thompson, Pharm.D., director of the Center on Patient Safety for ASHP, there is currently "a lack of consistency in what medication safety officers are doing from one institution to another. There are a lot of places doing some of the things that need to be done, but few places doing all the things that need to be done in order to have a true fail-safe medication-use system."

As a result, ASHP has implemented a new initiative to outline ideal roles and responsibilities for medication safety officers. The association intends to develop educational materials to train these professionals, with the ultimate goal being a medication safety officer in every U.S. hospital.

According to Sheldon Sones, R.Ph., FASCP, medication safety officer and assistant director of pharmacy at St. Francis Hospital and Medical Center in Hartford, Conn., "We observe the medication distribution process on a one-to-one basis and make sure that everyone understands that the focus is not 'who' but rather 'what' might possibly be embedded in the system that created the deviation."

As a result of focusing on "what" and not "who," some hospitals have implemented a nonpunitive medication error reporting system in which both medication errors and near-misses are reported. The goal of these initiatives is to increase the reporting of errors. After an error is reported, the jobs of a medication safety officer are quick and effective follow-up, incorporation of the details into a database, and implementation of systems to prevent recurrence. As much as 50% of a medication safety officer's time is spent following up on reported errors in the medication-use system.

The remainder of a medication safety officer's time is occupied with coordinating and implementing medication-use system improvements, not only for pharmacists but also for physicians and nurses. According to Rough, "Half of all errors are due to lack of information at the point of decision-making." As a result, one goal at his institution is for physicians to have all patient and medication information readily available to make better decisions using computerized medication prescribing integrated with laboratory results. This would, for example, enable a physician to choose a medication, evaluate laboratory results, and adjust the dose in the event of compromised renal function.

Another function of medication safety officers in the prescribing phase is to eliminate error-prone abbreviations in handwritten orders. This includes educating physicians on the importance of such things as writing dosages as "0.5" rather than ".5," to ensure the decimal point is not missed, and to avoid using "U" for units since a dose of 10 U written quickly is easily misinterpreted as 100.

To prevent errors in the drug administration phase, high-alert policies might be established for nurses. Specifically, a high-alert policy mandates special handling procedures for drugs with a high probability of causing harm if given in error. Such medications include insulin, heparin, and chemotherapy. For example, nurses may be required to have each dose of a high-alert medication double-checked by another healthcare professional prior to administration.

Potential errors can also be avoided at the bedside with effective use of bar-code technology. Patients, administering nurses, and the drug may be scanned prior to administration. In case of a breakdown in the system, nurses are alerted before a patient receives the medication in error.

In order to implement effective medication safety programs, both resources and personnel are necessary. "It helps if hospitals have forward-thinking administrators to approve the resources for medication safety personnel," said Rough. In addition, "a medication safety officer should be a pharmacist with great communication skills and attention to detail."

Many pharmacists enjoy being part of an interdisciplinary team of healthcare professionals responsible for developing and coordinating fail-safe medication-use systems and are well suited to carry the title of "medication safety officer." While day-to-day details for this new breed of pharmacist may vary, the ultimate goal of all medication safety officers is complete elimination of all medication errors.

Kelly Dowhower Karpa, BSPharm, R.Ph., Ph.D.

Based in Pennsylvania, the author writes frequently on pharmacy-related issues.

Kelly Karpa. Medication safety officer: A new breed of pharmacist.

Drug Topics

Sep. 3, 2001;145:26.