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Pharmacists building a safer health system.

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COMMENTARIES Building a safer health system

Pharmacists building a safer

health system
PHILIP J. SCHNEIDER
Am J Health-Syst Pharm. 2001; 58:66-8

ne of the most exciting events

for pharmacy in recent years
was the professions response to
the Institute of Medicine (IOM) report1 at the ASHP Midyear Clinical
Meeting in December 1999. After almost 40 years of pharmacy advocacy
of safer medication-use systems, including unit dose drug distribution
systems and intravenous admixture
programs, news that patient safety
was finally becoming a national public policy issue energized the entire
meeting. It seemed as though pharmacists would finally be able to take
center stage on an issue of great concern to the public. During the ASHP
meeting, a pharmacist was even invited to the White House to participate
in a press release announcing the receipt of the IOM report by President
Clinton. There was a sense that we
had finally arrived.
Patient safety is indeed a significant problem in health care. We
know that medication-related problems are the number one cause of adverse medical events. And, as shown
in the Harvard Medical Practice
Study, adverse drug events are more
common than infectious complications in hospitals.2 Most hospitals invest considerably more in infection
control than they do in improving
medication safety. It is time to
change this.
There is no guarantee that pharmacists will be asked, or will even be
able, to assume leadership in medication-error prevention, however. We
66

think this is our right as a profession,

yet others are also on the scene. More
than a year ago, I was asked to give a
presentation on the epidemiology of
adverse drug events to the Society for
Healthcare Epidemiology in America. The purpose was to encourage
hospital epidemiologists and infection-control departments (which are
staffed primarily by nurses) to broaden their focus to include medication
safety in their mission. Two physicians joined me in giving the presentation. When opportunityin this
case, a chance to stake a claim in medication error preventionknocks,
many people answer the door.
Pharmacists are well positioned to
take the lead in improving medication-use safety. The IOM report suggests several times that pharmacists
are an important resource in building
a safer health care system. Unit dose
systems and pharmacist participation
in medical rounds are two specific
recommendations in the report.
I think a closer look at the IOM
report is needed as we develop a
strategy for pharmacy to assume a
leadership role in improving the safety of health care. My review of the
report prompts me to suggest five
ways pharmacy could respond to the
opportunity that has been presented:
1. Establish an administrative

structure for improving the medication-use system. The medication-use

system is an interdisciplinary system
that requires collaboration among
prescribers, nurses, patients, and
pharmacists. An administrative
structure for setting goals, testing
change, measuring improvement,
and creating or recommending policy is often minimal in health systems.
Some organizations have no such
structure at all. A few have a nursing
pharmacy committee that addresses
improving medication safety, but this
committee typically does not involve
the medical staff and may lack the
policy-making or recommending authority needed for it to be effective.
Some institutions assign this responsibility to the pharmacy and therapeutics committee but do not allocate sufficient resources, including
time, for real progress to be made.
In my opinion, the best administrative structure for improving medication safety is a physician-led committee composed of prescribers,
nurses, pharmacists, and risk-management personnel. In most settings,
this body is best structured as a subcommittee of the pharmacy and therapeutics committee, with a pharmacist
serving as secretary. That pharmacist
should be a person with understanding
of and commitment to improving or-

PHILIP J. SCHNEIDER, M.S., FASHP, is Clinical

Professor and Director, Latiolais Leadership
Program, The Ohio State University, 500 West
12th Avenue, Columbus, OH 43210-1291.
Presented at the ASHP Annual Meeting,

Philadelphia, PA, June 5, 2000.

Am J Health-Syst PharmVol 58 Jan 1, 2001

Copyright 2001, American Society of

Health-System Pharmacists, Inc. All rights reserved. 1079-2082/01/0101-0066$06.00.

COMMENTARIES Building a safer health system

ganizational performance and safety.

At Ohio State, it has been our experience that this type of subcommittee
needs to meet at least two hours a
month to be successful.
2. Help create an environment for
improvement. It is well recognized
that the right environment for improving patient safety does not currently exist within health care. Too
often, there is a fear of reporting
problems with patient safety because
of fear of discipline or legal action,
unwillingness to invest in changes
that will improve safety, and concern
about the image of the health system.
Performance appraisals often penalize the staff for making mistakes. For
example, our pharmacy at Ohio State
is often asked for information from
our medication error-reporting program to assist in evaluating individual nurses, or for information from
pharmacist intervention programs to
assist in physician credentialing.
How can nurses and physicians support voluntary improvement programs when the results of these programs may adversely affect their performance appraisals?
Why not reward nurses for reporting errors and near-misses? Why not
use performance improvement as
part of physician-credentialing programs? These are very simple changes
in philosophy that prepare the landscape for improvement. Pharmacists
can lead in recommending such
changes to increase measurement
and monitoring of the medicationuse system. These changes will also
make it more possible to use the information gained from monitoring
to work collaboratively with nurses
and physicians in order to improve
patient safety. Examples of how we at
Ohio State have been able to improve
medication-use safety include teaching nurses about the difference between hydromorphone and morphine and teaching physicians that
certain antimicrobial combination
products that are usually prescribed
by brand name contain a penicillin.3

This has reduced the number of cases

in which hydromorphone was administered instead of prescribed
morphine or in which patients with
penicillin allergies received penicillin-containing combination antimicrobials.
Two years ago we sponsored a
program on improving the medication-use process by driving fear out
of the workplace. An excellent review of the problem of fear in the
workplace has been presented by
Ryan.4 Workshops were held to address the fear issue, talk to the public
and the press about errors, minimize
liability, and create performance appraisals that reward improvement.5
3. Implement best practices. We
need not start from scratch to improve medication-use safety. Nor
must we wait for an optimal administrative structure or a conducive environment in order to begin implementing what we already know are
safe practices. Lists of these practices
have been published by ASHP, the
Institute for Safe Medication Practices, the Institute for Healthcare
Improvement, USP, the General Accounting Office, and IOM. All pharmacists should review the recommendations of these organizations
and prepare a checklist to use in auditing their own system.
Best-practice recommendations
listed in the IOM report are as follows:
Improve voluntary reporting of adverse drug events and near-misses,
Implement computerized prescriber
order-entry systems,
Use a unit dose distribution system,
Do not stock concentrated medications in patient care areas,
Include pharmacists in patient care
rounds,
Use machine-readable technology
(bar coding), and
Check patients arm bands to verify
their identity.

4. Measure the performance of the

medication-use system. Langley et al.6

described three components of improvement in their book The Improvement Guide: establishing a goal,
creating a measurement system, and
identifying changes that might result
in improvement. They suggest asking
what the goal is, what changes will be
needed for improvement to occur,
and how we will know when the
changes result in improvement.
Measuring the performance of the
medication-use system is difficult.
Quantitative measures of performance involving scientifically valid,
observation-based medication-error
studies have been criticized for focusing only on medication errors. These
often measure only dispensing and
administration errors and identify
disproportionate numbers of errors
that do not result in adverse drug
events. This approach compares drug
administration with the physicians
order, which is assumed to be correct. It is now recognized that 39% of
adverse drug events are the result of
errors in prescribing.7 These observation-based medication-error studies
have been a mainstay of performance
measurement in the medication-use
system.
Reliance on voluntary reports of
events has been found to be a poor
method of measuring performance.
Just 0.2% of errors are detected by
this method.8 In contrast, 0.7% are
detected by population review and
3.8% by computer alerts. A combination of methods is usually much better at detecting events, but the best
detection rates usually approach only
10%. Thus, at best, measurement systems are semiquantitative. Perhaps
advances in information technology,
including computerized order-entry
systems and bedside bar-coding systems for documenting drug administration, will enable more fully quantitative reporting. In the meantime, a
combination of methods, including
stimulated voluntary reports, alerting orders (orders for antidotes and
drugs used to treat adverse drug

Am J Health-Syst PharmVol 58 Jan 1, 2001

67

COMMENTARIES Building a safer health system

events), surrogate laboratory measures (International Normalized Ratio, prothrombin time, serum drug
concentration), pharmacist interventions, and medication-use-evaluation studies, will have to suffice.
5. Test proposals that have the potential to improve medication use.
With best practices and a good measurement system in place, opportunities to improve medication use will
continually be found. Pharmacists can
and should step forward to discuss the
problems identified and suggest solutions. Measurement systems will enable system changes to be evaluated.
Many health systems have standardized their approach to heparin
with weight-based heparin protocols
designed to reduce the frequency of
adverse events associated with this
drug. A test of such protocols might
involve tracking abnormal prothrombin times, bleeding episodes,
and the use of protamine and fresh
frozen plasma. A less rigorous proposal might be an educational program on the subject of heparin use. A
more rigorous proposal might be implementing a voluntary or mandato-

68

ry anticoagulation management service. New programs could be tested

until the desired level of patient safety is achieved.
A little over 10 years ago, when
cost-containment pressures were first
starting to affect pharmacy, a fellow
member of the ASHP Board of Directors asked me if I ever wished that I
had been in pharmacy during the
exciting 1960s, when unit dose, i.v.
admixture, and clinical programs
were being implemented. I did not
agree then and I do not agree now
that the present is less exciting than
those past times. Our leaders have the
same kinds of challenges today that
we had in the 1960s and in the late
1980s. What was needed then and is
needed now is the vision to recognize
the opportunities presented to pharmacy by the unrest and dissatisfaction within health care. I have tried to
suggest five specific ways that pharmacy can respond to the publics
concern about safety in health care
that has been so well described in the
IOM report. A measure of leadership
within pharmacy will be our ability to
contribute positively to the debate on

Am J Health-Syst PharmVol 58 Jan 1, 2001

improving safety. I hope my suggestions will provide a good start.

References
1. Kohn LT, Corrigan JM, Donaldson MS,
eds. To err is human: building a safer
health system. Washington, DC: National
Academy Press; 1999.
2. Leape LL, Brennan TA, Laird N et al. The
nature of adverse events in hospitalized
patients. Results of the Harvard Medical
Practice Study II. N Engl J Med. 1991;
324:377-84.
3. Schneider PJ, Hartwig SC. Use of seventyindexed medication error reports to improve quality. Hosp Pharm. 1994; 29:205,
208-11.
4. Ryan KD. Driving fear out of the medication-use process so that improvement can
occur. Am J Health-Syst Pharm. 1999;
56:1765-9.
5. Schneider PJ. Creating an environment for
improving the medicaiton-use process.
Am J Health-Syst Pharm. 1999; 56:176972.
6. Langley GJ, Nolan KM, Norman CL et al.
The improvement guide: a practical approach to enhancing organizational performance. San Francisco: Jossey-Bass;
1996.
7. Leape LL, Bates DW, Cullen DJ et al. System analysis of adverse drug events. JAMA.
1995; 274:35-43.
8. Jha AK, Kuperman GJ, Teich JM et al.
Identifying adverse drug events: development of a computer-based monitor and
comparison with chart review and stimulated voluntary report. J Am Med Inform
Assoc. 1998; 5:305-14.