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Lawrence 1 Taylor Lawrence ENG 101 Professor Bolton April 8, 2014 Medication Safety: Is Training Necessary?

Medication safety is a big part of todays health care industry. Practicing medication safety is a must for any health care profession, but it is extremely important in the pharmacy world. Taking a few extra minutes to assure all work is correct is something that can save lives, but is at times neglected. Some may argue that an individual that makes the medication error is solely responsible; however, did they receive an adequate amount of training? Were the training techniques used correct and efficient? Along with training, using resources to check completed work is considered a best practice. Some people may consider a health care professional using additional resources to ensure nothing was missed during their workflow is equivalent to not knowing how to do their job; nevertheless, reference checking any doubted work is a gold standard in health care. Using the correct training techniques and reliable healthcare education resources can dramatically reduce medical errors. By practicing the correct training techniques for working in a professional medical institution, the number of medical errors can be reduced. William Ellis, the executive director of the Board of Pharmacy Specialties (BPS), stated in an article from the American Journal of Health-System Pharmacy Were in what I believe is the era of accountability for healthcare . . . and that has demanded the expansion of

Lawrence 2 clinical knowledge and competence of all pharmacists, (552). With Ellis saying this, he is referring that accountability is a key factor in the pharmacy world and for that matter, a key factor in every job setting. Now, expanding clinical knowledge and competence, especially in pharmacy, requires what kind of actions? It requires training. Everything requires training; however, training is overlooked more than one would think. Some may say that when medical errors are made, the individual that was present is solely responsible. On the other hand, I say that whether the individual was trained properly or not comes into play. Constant training is extremely important in the medical field. Procedures are constantly changing everyday and can be quite hard to keep up with. Training is not always done before a new task is attempted and errors seem to follow when training is failed to be put first. No wonder so many medical errors are reported every year. Medication Safety: Dispensing Drugs Without Error is an informative book that breaks down training techniques that are to be followed when working in a pharmacy. The interesting thing about this book is that it provides actual scenarios with medication errors that were made and ended with a trial in court. For example, the book uses the trial case of The Case of the High School Student. In this case, a pharmacy hired a high school student to be a register clerk the student was not a certified pharmacy technician. A woman came in the pharmacy to pick up her daughters prescription and the register clerk recognized the daughters name while checking the mother out. Later that week, the register clerk spread the rumor that the daughter was taking birth control pills. What the register clerk did not know was that the daughter was taking the medication for acne not as contraceptives. This rumor was a violation of

Lawrence 3 HIPAA (Health Insurance Portability and Accountability Act), in which insures patient confidentiality. The register clerk was never trained correctly and did not know that she was supposed to keep a patients medical background confidential (129). With just a little training the register clerk would have been aware of the law of HIPAA. Training should be one of the most valued aspects of working in the medical field or in any field of work, for that matter. According to the book, Preventing Medication Errors: Quality Chasm Series, there were 770,000 ADEs (Adverse Drug Errors) reported in hospital patients in 2005 that could have been prevented with better training strategies. Even though medical errors can be prevented when protocol is followed, there is no possible way for errors to completely stop being an issue. It is basically human nature to make mistakes doing any task however, knowing how to do a job right can decrease the chances of errors taking place. When errors are made during the workflow in a medical institution, certain steps are to be followed. According to Medication Safety: Dispensing Drugs Without Error, in order to correctly train an individual the problem needs to be identified first. After the problem has been identified, a process will be put into play to help the individual understand where he/she is making the mistake (46). Training is most important at a beginner level and even throughout school. Students have exclusive access to hundreds of databases that provide videos and interactive material to make training easy and fun. Films on Demand is an online database with hundreds of videos ready to be watched. These videos are available to students through their school library. They can be extremely helpful for medical school students. Training videos can also be considered Continuing Education. Continuing

Lawrence 4 Education or CEs are online interactive programs and live conferences that are required to be completed each year by health care professionals from the South Carolina Department of Health and Environmental Control (SCDHEC). Training is incorporated into these seminars and videos however, a health care worker must take it upon themselves to makes sure each CEs potential was fulfilled. Training is only effective when taken seriously and with effort put forth. Decreasing medical errors can be achieved by something as little as a 15 minute training video. Using the correct training procedures for health care professionals and even students can help decrease the amount of medical errors in any health care institution. Along with the correct training techniques, using reliable educational resources as reference can help decrease the amount of medical errors made. Working in a medical institution, especially a pharmacy, it is always a good idea to have a reliable reference on hand. With personal experience as working in a hospital pharmacy and retail pharmacy throughout my college career, I have realized that referring back to a reliable resource has saved myself from making errors countless times. Some people may think that having a reference sheet or book on hand while on a job site can be considered cheating or that you may not know how to do your job. However, it is considered a best practice to check your work with an educational resource to insure that no errors will be made. Health care professionals have exclusive access to some of the best educational programs and organizations that provide great references. The ISMP (Institute for Safe Medication Practices) website has a lot of reliable resources. The website is very useful not only for the pharmacy world, but for the entire medical field. The resources include lists

Lawrence 5 of medications that are not to be crushed to videos of insuring patient safety and anything in between. Being able to access these resources has made my school career in pharmacy much easier and has made my time working at the pharmacies more comfortable. Using error prevention strategies can also be considered as educational resources. Preventing Medication Errors: Quality Chasm Series lists several different prevention strategies that have been put together by an expert panel of health care professionals and have been tested to the strategies full potential. These strategies are documented for medical institutions that are having reoccurring errors in the same area of the workflow to refer to. These strategies are even backed up with the amount of evidence they received after the strategy was put to use. For example, the book states that monitoring for look alike and sound alike medications have had a medium evidence outlook in most pharmacies (412). Medium evidence means that after this strategy was put in place, the rate of medical errors in this certain place in the workflow was decreased and change was noticed. Using educational reference guides can save you from making a mistake but using them also makes for a better working environment. Better work environments lead to a more polished workflow and less room for error. Medication Safety: Dispensing Drugs Without Error provides another trial case where the error could have been prevented with just a simple double check of the work. The Case of Sr., Jr., and the III involves three different men with the same name, from the same family. All three men got their prescriptions filled at the same pharmacy. A prescription for the father, Carl, Sr. was filled for the son, Carl, Jr. it was a heart medication. The son never realized he was taking his fathers heart medication and

Lawrence 6 ended up passing away (41). A life could have been saved if the pharmacy would have paid enough attention to detail. Using reliable references to check all work done in a health care institution can dramatically decrease the amount of medical errors reported annually. Whether health care institutions use more advanced training procedures or implement professionals use the best practice of checking their work with supplemental resources, medical errors will be subject to decrease. Most health care professionals have unlimited access to the best educational Expressing the importance of taking extra precautions and paying attention to detail is some things every health care facility needs partake in. Health care professionals need to realize the importance of making sure all jobs are done correctly especially jobs that involve the well being of innocent civilians. Just imagine what the health field would be like if every health care professional care about the importance of training and reference checking all work.

Lawrence 7 Works Cited Baker, Kenneth R. Medication Safety: Dispensing Drugs Without Error. Clifton Park, N. hY.: Delmar/Cengage Learning, 2013. Print. "Institute For Safe Medication Practices." Institute For Safe Medication Practices. N.p., n.d. Web. 10 Apr. 2014. Aspden, Philip. Preventing Medication Errors: Quality Chasm Series. Washington, DC: National Academies, 2007. Site.ebrary.com.storm.hgtc.edu. National Academies Press. Web. 13 Apr. 2014. "Specialization: Key to Evolving Health Care Environment." American Journal of Health System Pharmacy 71 (2014): 552-53. Academic OneFile. Web. 13 Apr. 2014. Pharmacy Technician. Pharmacy Careers: Training and Responsibilities. Films Media Group, 2002. Films On Demand. Web. 13 April 2014. http://storm.hgtc.edu:2048/login?url=http://digital.films.com/PortalPlaylists.aspx ?aid=3503&xtid=29322

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