Drug Topics - March 3, 2008 - (Page 3)

3 REDUCING YOUR RISK Ken Baker, B.S.Pharm., J.D Reducing medication errors requires a non-punitive approach n a cloudy night in December 1974, a TWA airliner was approaching Dulles Airport in the suburbs of Washington, D.C. Misunderstanding a communication, the plane dropped below what was considered a safe altitude. TWA flight 514 struck a mountain top, killing all aboard. During the NTSB investigation it was discovered that a few weeks earlier a United flight experienced an eerily similar communication misunderstanding and narrowly avoided suffering the same fate. Had the TWA flight been warned of the United aircraft’s experience, the result might have been different. From that lesson evolved a partnership between NASA and the FAA that led to the creation of the national Aviation Safety Reporting System (ASRS). Today, information such as might have saved the passengers aboard TWA 514 is shared throughout aviation. Reports of every accident and near-miss are reported and analyzed. ASRS has led to a quality system of continuous improvement, often described as the best in the world. The National Institutes of Health has said we in the medical field can learn a lot about quality from NASA and ASRS. One lesson is the importance of collecting and sharing information, not only about each error, but, at least equally important, each near-miss. My experience working with pharmacy quality systems is we can often learn more from the mistake that was caught, before it reached the patient, than from the error that caused injury. From the ASRS model we can develop a simple strategy: •If you want to know why someone did something, ask him or her. •People are willing to share their experiences if they can do so anonymously. They will not share if they believe doing so may subject them to punishment. •A reporting system must be confidential and nonpunitive. O This article does not constitute legal or consultative risk management advice. You should not rely on the information here for a plan of quality or for legal matters. Consult a risk management consultant or an attorney. •A reporting system can be used to discover why a system failed or a person erred. •A system cannot succeed without the cooperation of those using it. •A system should exclude intentional acts from the data. •The data collected can be used to identify vulnerabilities in the system. •Data collected can be used to prevent future errors and injury only if there are data collected. According to a study at Auburn University, pharmacists make one mistake with each 65 prescriptions dispensed. In this country, it is estimated that more than three million potentially serious prescription errors walk out of community pharmacies each year. I have talked to prosecutors and board members who have tried to explain to me that their actions regarding punishing pharmacists for making an error was to prevent future errors and injuries. They are wrong. They should not think their punitive actions will have a positive impact on safety. It will probably have the opposite effect. Other pharmacists will become reluctant to share information about a mistake they made. Lessons will be lost. The pharmacy equivalent of TWA 514 may not be prevented. A pharmacy can institute a non-judgmental, nonpunitive system for staff to share information and learn from the mistakes we all make. If your pharmacy does not have a quality system that can be used to tell you where, when, and what kind of mistakes are made in your system, you should consider instituting one. One such system is available through your state pharmacy association. The program is inexpensive – no, actually, it is cheap. The Pharmacy Quality Commitment system is available through all state associations, thanks to the National Alliance of State Pharmacy Associations, a nonprofit organization dedicated to safety and pharmacy. When you put such a system in place, follow the guidelines set out by NASA and the ASRS reporting model. In particular, make sure reporting is non-punitive. consults in the areas of pharmacy error reduction and risk management. He is an attorney, of counsel, with the Arizona law firm of Renaud Cook Drury Mesaros, PA. References for this article are available at kenbakerconsulting.com. THE AUTHOR http://kenbakerconsulting.com

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Drug Topics - March 3, 2008

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