Magazine article Drug Topics

Medication Safety Officer: A New Breed of Pharmacist

Magazine article Drug Topics

Medication Safety Officer: A New Breed of Pharmacist

Article excerpt

HOSPITAL PRACTICE

In the United States, up to 7,000 patients die annually from medication errors, but as many as 40% of these errors could be prevented. Those statistics, according to Steven Rough, M.S., R.Ph., director of the pharmacy service organization at the University of Wisconsin Hospital and Clinics, are the reason he is actively looking to recruit a pharmacist to fill a new position, that of medication safety officer.

Rough said, "Errors are usually fueled by faulty 'system' design. Our goal is to improve 'systems' to prevent future errors." Pharmacists are a crucial link in the medication-use process, so it makes sense to utilize them to oversee all aspects related to safety and quality assurance in hospitals.

According to Kasey Thompson, Pharm.D., director of the Center on Patient Safety for ASHE there is currently "a lack of consistency in what medication safety officers are doing from one institution to another. There are a lot of places doing some of the things that need to be done, but few places doing all the things that need to be done in order to have a true failsafe medication-use system."

As a result, ASHP has implemented a new initiative to outline ideal roles and responsibilities for medication safety officers. The association intends to develop educational materials to train these professionals, with the ultimate goal being a medication safety officer in every U.S. hospital.

According to Sheldon Sones, R.Ph., FASCP, medication safety officer and assistant director of pharmacy at St. Francis Hospital and Medical Center in Hartford, Conn., "We observe the medication distribution process on a one-to-one basis and make sure that everyone understands that the focus is not 'who' but rather 'what' might possibly be embedded in the system that created the deviation."

As a result of focusing on "what" and not "who," some hospitals have implemented a nonpunitive medication error reporting system in which both medication errors and near-- misses are reported. The goal of these initiatives is to increase the reporting of errors. After an error is reported, the jobs of a medication safety officer are quick and effective follow-up, incorporation of the details into a database, and implementation of systems to prevent recurrence. As much as 50% of a medication safety officer's time is spent following up on reported errors in the medication-use system.

The remainder of a medication safety officer's time is occupied with coordinating and implementing medication-use system improvements, not only for pharmacists but also for physicians and nurses. According to Rough, "Half of all errors are due to lack of information at the point of decision-making. …

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