Magazine article Drug Topics

Patient Safety Officers: A Newly Emerging Role for Pharmacists

Magazine article Drug Topics

Patient Safety Officers: A Newly Emerging Role for Pharmacists

Article excerpt


Following the 1999 Institute of Medicine report on patient safety, many states passed leRislation designed to curb medical errors. In 2001, 22 states passed laws to ensure higher levels of patient safety. In 2002, 64 pieces of such legislation are expected to surface.

An example of the types of bills being passed is the recent signing of landmark legislation in Pennsylvania by Gov. Mark Schweiker. The Medical Care Availability & Reduction of Error Act requires hospitals to submit a patient safety plan, including the designation of a patient safety officer (PSO), to the state department of health by July 18.

With heavy pressure to reform their system, many hospitals have appointed PSOs. These individuals are responsible for reporting medical adverse events and studying solutions to overcome identified problem areas. To effectively do this, one needs to understand where the hospital is vulnerable and enact systems to prevent future errors.

A new group, the Patient Safety Officer Society (PSOS), was officially launched on June 1 to address the needs of those suddenly finding themselves in this new role. David Bernard, M.D., executive vp. and chief medical officer for DoctorQuality Inc., said the society was started because of "a need to focus on common issues, to learn from one another, and share common experiences."

David Shulkin, M.D., president of PSOS, said, "Our focus will be to lead change efforts, fighting against problems for decades to come." Although PSOS is new, it already boasts 250 members from all over the world. About 25% of its members are pharmacists.

"Medical errors most commonly result from clinical or administrative mistakes," said Bernard. He cited such mistakes as leaving a sponge inside a body cavity after surgery or operating on the wrong body part as examples of clinical errors. Administrative errors include mishaps like failing to put a bed rail up and having a patient fall out of bed or X-raying the wrong patient. Interestingly drug errors constitute a small piece of the medical-- error pie-accounting for only 35% of all med errors.

Pharmacists who are appointed to PSO positions often assume the rules of medication safety specialists. Colleen Malashock, PharmD., medication safety specialist with the Nebraska Health System, reported that her job primarily involves "getting medication-error reports within the institution, observing trends, and implementing plans to facilitate performance improvement."

When serious errors-errors that cause harm to patients-are reported, Malashock performs a root-- cause analysis to determine where system breakdowns occurred. …

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