The Patient Safety Act — Always One Day Closer to a Fatality?

“Good morning, ladies and gentlemen. Thank you for an outstanding safety performance yesterday. We are one day closer to our next fatal crash.” When I was in the Air Force, one colonel would start all of our safety briefings with this statement. To this day, his statement has stuck with me because it is so true about life. Focus is needed in many walks of life, but for patient safety it is needed every day. Every pharmacy across the country is always one day closer to dispensing a fatal dose of medication. Regrettably, over time people can become comfortable and complacent. When those two items are combined, it creates the perfect environment for an accident to occur. Pharmacists can fill hundreds of prescriptions a week, and unfortunately, in order to meet the demands of pharmacy life, they may overlook small steps and have a misfill occur.

To help improve patient safety and reduce misfills, everyone in the pharmacy must be involved in quality control; helping to identify missteps and errors, and being aware of sound-alike/look-alike drug fills, are ways to ensure you are taking proactive measures. Errors found behind the counter are quality control, errors going out the door are medication errors. Errors do happen, and it is important to understand what you need to protect yourself, as well as your patients. The Patient Safety and Quality Improvement Act (Patient Safety Act) requires that a continuous quality improvement (CQI) program be implemented. A CQI program is designed for detecting, documenting, analyzing, and preventing quality-related events (QREs), with the intent of preventing medication errors.

A CQI program creates an environment that makes quality the top priority and allows pharmacy staff to learn from past mistakes, while focusing on improving patient safety by decreasing errors and increasing quality. Pharmacy staff must be willing and open when discussing all failures of quality. Reporting errors should not lead to blame or punishment, but instead need to be seen as an opportunity to learn and improve. When an error occurs, your first question should be, “What in our system allowed this error to occur?”

A proper CQI program will:

  • Designate an individual or individuals to be responsible for monitoring CQI program compliance.
  • Identify and document QREs.
  • Minimize the impact of QREs on patients.
  • Analyze data collected in response to QREs to evaluate causes and discover contributing factors.
  • Incorporate findings to formulate an appropriate response and develop a corrective action plan.
  • Provide ongoing education, at least annually, on CQI related to pharmacy personnel systems and workflow processes designed to prevent QREs.

Pharmacies must recognize that problems exist — problems that unavoidably cause mistakes to happen. These are systems problems; to change the outcome and prevent the same error from occurring in the future, we must change the system. To start improving your quality of care, a few simple questions can help open the dialog with staff.