Role of Pharmacy in Medication Errors (TEST 3)

•Feel pressured or intimidated to meet metrics

•Feeling concerned about losing their job

•No breaks in long work days

How chaos in chain pharmacies is putting patients at risk:

WHO

the study of all the factors that make it easier to do the work in the right way

-individual characteristics

-tasks performed

-tools/technology

-status of physical space

-supportive organization

What are the 5 elements for a safe environment?

-sort

-set in order

-shine

-standardize

-sustain

What is the 5S in the workspace used for product verification/dispensing?

•Report it! To your supervisor

•Correct it

•Review for change

What should you do when you make a mistake?

1.Make disclosure mandatory

2.Training on effective/sincere apology

3.Do not procrastinate

4.Protect staff who report incidents (Just Culture)

5. Generally, the person who made the error is NOT:

•the one to disclose the event to a patient (most times)

•Be responsible for the correction of practice

What are the medical error disclosure suggestions?

1) reporting

2) reaching out

3) review

4) resolution

What are the 4 R's of medical error disclosure?

reporting

•Have a policy

•Include critical information

reaching out

•Have an appointed spokesperson

•Meeting b/w patient/family

review

looks at root cause analysis, ect. How did this happen?

resolution

provide all pertinent findings to patient family

second victim

The impact of a medication error goes beyond just the patient and their family, it can also affect the healthcare employee

-difficulty sleeping

-reduced job satisfaction

-guilt and anxiety

-burnout

-depression

-suicidal ideation

What are some things that can be caused by "second victim"?

TRUST

T-treatment that is just

R-respect

U-understanding and compassion

S-supportive care

T-transparency and the opportunity to contribute their learning

What are the 5 rights of the "second victim"?

second victim team responsibilities

•Support the person who made the error

•Create an environment that promotes honesty and allows staff to feel comfortable admitting mistakes

•Supporting your colleague is the responsibility of the entire team, peers, and management

•Do not judge the event by its outcome

•Take the time to understand the surroundings/environment at the time of the event