Patient Safety in Community Pharmacy Practice - Dr. Bursua

What are the 5 components of the community pharmacy workflow?

Order Entry --> Order Verification --> Order Preparation/Filling --> Product Verification --> Dispensing

What is one significant challenge in community pharmacy?

Maintaining an accurate patient profile

What types of unsafe acts are common in the order entry process?

- Slips

- Knowledge-based mistakes

Provide an example of a "slip" in order entry.

Chose the wrong drug from the list (error --> action did not go as intended --> slip due to error of execution)

Provide an example of a "knowledge-based mistake" in order entry.

Technician selected the wrong dosage form of diltiazem. The technician did not know there was a difference between ER and CD formulations. (error --> action goes as intended but is wrong --> mistake --> knowledge based since tech did not know this was wrong)

How can we prevent slips in order entry?

- Modify design

- Double checks

How can we prevent mistakes in order entry?

- Training

- Modify workflow

- Double check

How can we overall reduce mistakes in order entry?

Automation --> removes the human from the process

What types of unsafe acts are common in the order verification step?

- Lapses in order entry check

- Knowledge-based mistakes in clinical checking

- Violations in clinical checking

How do knowledge based mistakes occur in order verification?

RPh may lack knowledge of patient (e.g. allergies, current weight) or clinical knowledge (e.g. drug interactions or correct dosing)

What is a routine violation?

A common place violation committed by most members of the workforce. Passes the substitution test

What is a situational violation?

Occurs in response to situation factors such as inadequate time or equipment to follow the rule or standard (trying to provide expedient care + high productivity)

What is an exceptional violation.

Uncommon occurrence that happens in abnormal or emergency circumstances. Staff believe the rules no longer apply/ following that rule will not result in the desired outcome. (risk is thought to be justified)

How can we prevent lapses in order entry checking?

- Increase attentiveness

- Promote situational awareness

- Reduce distractions

- Improve upstream process through automation

How can we prevent mistakes in clinical checking?

- Increased access to high quality patient information

- Present clinical risks more clearly

How can we prevent violations in clinical checking?

- Modify incentive structure

- Coaching

- Increased mindfulness of risks

Many tasks in the order filling step of workflow can depend on _____ intervention.

Human

What are 3 strategies to reduce risk in order preparation/filling?

- Optimal use of technology (barcoding, automated dispensing, automatic population of lot/expiration date)

- Double checks (product verification)

- 5 S's of Lean

What are the 5 S's of Lean?

- Sort

- Set in order

- Shine

- Standardize

- Sustain

What are the 8 benefits of the 5 S's of Lean?

- Improved safety

- Better use of equipment

- Lower defect rate

- Reduced costs

- Increased production agility and flexibility

- Improved employee morale

- Better asset utilization

- Enhanced enterprise image to customers, suppliers, employees, management, auditors

What types of unsafe acts or errors are most common during the verification process?

- Violations

- Slips or Lapses

How can we reduce risk in product verification?

- Identify high risk scenarios (e.g. product not scanned)

- Standardize workflow (one patient at a time)

- Reduce/ eliminate interruptions

- 5 S methodology

What types of unsafe acts are most common during product dispensing processes?

- Violations

- Slips

- Knowledge-based mistakes

What are 3 ways we can reduce risk at the dispensing step?

- Use 2 pt identifiers

- Open rx bag and review with pt at POS

- Counsel pts

How can community pharmacies communicate with external systems?

Operationalize e-prescribing tools like CancelRx, EPCS, ChangeRx, ILPMP, transmission of allergy information

What are some strategies for patient safety in community pharmacy, overall?

- Provide instructions in readable format

- Set expectations for counseling on high-risk medications that are frequently misused

- PMP review in order verification

- Cultivate a culture of safety

Are community pharmacies included in the AHRQ Survey on Patient Safety Culture (SOPS)?

Yes!

What were the two lowest scored categories for community pharmacies in SOPS? What type of violation do these promote?

- Physical Space and Environment

- Staffing, Work Pressure, and Pace

This promotes situational violation!