Support your Pharmacy’s Just Culture Journey

To err is human – yet in many pharmacies, medication errors are not reported due to fears of disciplinary or legal action. This inclination is having serious consequences on patient safety. Every year in the US, an estimated 7,000 to 9,000 people die as a result of a medication error, while hundreds of thousands more experience adverse reactions and other complications.

Though medication errors may never be completely avoidable, to help improve patient safety, boards of pharmacy have enacted quality assurance and reporting measures for pharmacies to consistently report medication errors and near-miss events (aka good catches). Absent consistent reporting, it is impossible to identify process gaps that led to the incident or near-miss, and what steps should be taken to avoid a repeat of the error.

Many states are also working to improve patient safety by introducing “just culture” concepts and encouraging reporting in a transparent environment that focuses on learning. The APhA House of Delegates also recently approved six policies to guide US pharmacies working to establish a just culture approach to patient safety to further encourage reporting and improve medication safety. In short, if a pharmacist complies with reporting to address the root cause of medication errors, then patient safety and risk management will be improved.

Implementing technology like Pharmapod provides a safe space to foster your just culture. Pharmapod’s Patient Safety Organization (PSO) contains a medication incident reporting platform that can help your pharmacy comply with state requirements and APhA guidelines, while enhancing patient safety and limiting legal risk.

Improving Patient Safety Starts with a Just Culture

Establishing a just culture is the first step to improving patient safety. In a just culture, pharmacy staff understand that patient safety is a top priority, and continually look for risks that pose a threat. Unintentional mistakes are treated as learning opportunities, where the focus is on identifying what went wrong in the process, rather than shaming or blaming individuals.

When medication errors do occur, employees feel comfortable taking responsibility for their actions, knowing they will not be penalized for mistakes made in good faith.

As more errors and near-miss events are reported and more process gaps are identified and fixed, the foundation to avoiding errors in the future and reducing the risk of patient harm and subsequent legal action become reality.

Pharmapod Simplifies Reporting

To gather the data needed to identify potential risk in your pharmacy, pharmacy staff must consistently report both medication incidents and near-miss events. Pharmapod’s medication incident reporting platform makes it easy. When reporting, the platform walks users through a series of predefined questions with multiple required fields to ensure all relevant information surrounding the incident is captured.

Pharmacy staff can be given varying degrees of access so they’re able to contribute to reports as needed without seeing information that isn’t relevant to them. Including all team members in incident reporting helps improve engagement and enhance accountability, critical factors when establishing a just culture.

From there, it’s easy to aggregate and analyze data – not only from your pharmacy, but also from other aggregated data – to perform a root cause analysis, identify trends and problem areas, and proactively improve processes. Pharmacy management can also quickly generate reports and share findings with team members and other pharmacy locations when applicable to prevent similar incidents from occurring elsewhere.

Patient Safety Organization Provides Legal Protections

The Pharmapod platform takes it one step further with a Patient Safety Organization (PSO) that offers critical legal protections designed specifically for pharmacies. The PSO protects certain information reported to the PSO, such as through the incident management platform, from legal discovery (minus a few exceptions including malicious intent or criminal behaviors).

Privilege and confidentiality of any patient safety improvement work performed within the PSO can never be waived, meaning pharmacy staff can feel safe and comfortable in honestly and accurately reporting errors and near-miss events.

This provides a safe space to foster your just culture, encourages open and transparent communication, helps ensure process gaps are more quickly identified and proactively addressed, and enables you to better evaluate the effectiveness of your continuous quality improvement (CQI) initiatives.

How do PSOs Work?

The following scenario illustrates how a PSO could work for your pharmacy:

Jane suffers from depression and takes 50 mg of Apo-Desvenlafaxine daily. In September 2021, she refilled her prescription, noticed that the pills were a different color and assumed it was a manufacturer change.

Jane continued to take her medication as prescribed but noticed that her depression was worsening to the point that she was having suicidal thoughts. In early December, Jane checked her pill bottle to see when she would need her next refill. Although she touched the bottle daily to retrieve her medication, this was the first time she had looked at the label - and she noticed that these pills were not only different in color, but also in strength.

Jane’s prescription was for Apo-Desvenlafaxine 50 mg, however, the pharmacy had refilled it with Apo-Desvenlafaxine 100 mg instead - double the strength. She called the pharmacy where she was instructed to take only half a pill until they were gone.

Fortunately, no permanent harm came to Jane, however, she did suffer temporary harm for approximately 3 months of worsening depression. A medication safety error had occurred. Upon learning of the error, the pharmacy entered the information into the Pharmapod medication safety incident reporting platform, including a root cause analysis, and implemented an action plan subsequent to its findings.

A month later, the pharmacy received a letter of intent to file a lawsuit against the pharmacy and a request for all of the pharmacy’s records relative to the error. As the pharmacy is a member of a PSO, and had reported the error to the PSO, much of the information is protected and not subject to discovery.

The facts of the case are not privileged or confidential. The PSO does not protect and cannot hide the fact that Jane received the wrong strength of her medication. The value of the PSO in this instance is in protecting what happened within the pharmacy after the error was discovered and entered into the reporting system. That information is considered Patient Safety Work Product (PSWP) and is protected under the PSO as patient safety improvement activity.

The pharmacy performed a root cause analysis and found that both strengths of the medication are in similar bottles from the manufacturer - the bottles were identical in size, the labels were the same colors with no easily identifiable differences and were stocked beside each other on the same shelf. As a result of the RCA and subsequent action plan, the following actions were taken:

1. All pharmacists were re-educated to always double check the label against the prescription before handing medication to a patient;
2. The pharmacy wrote a letter to the manufacturer to let them know about the error and to ask that they consider making more distinctions between the bottles; and
3. The pharmacy changed the location of the medications on the shelves so that they are no longer side-by-side.

While medication errors may never be completely avoidable, regular reporting in the Pharmapod platform can help you learn from past mistakes to prevent future errors.

Protect your pharmacy, improve patient safety, and support your just culture journey- contact Pharmapod today to learn more about our PSO solution and how it can help limit medication errors and reduce risk in your pharmacy.

About Pharmapod

Pharmapod is the leading cloud-based CQI solution for driving efficiencies and reducing patient safety incidents in community pharmacies, acute care, and hospital settings. Built by pharmacists for pharmacists, our technology is used globally by industry leaders, regulators and national healthcare providers to promote data-driven innovation, safety and quality improvements. Pharmapod is a member of the Think Research family of companies.