Innovations-Magazine-May-2023 - 10

Medication errors are a significant concern in pharmacy and
health care as a whole. NABP will continue to take crucial steps
to address this issue, and to help promote a better working
environment for pharmacists and technicians at all levels.
Incidents like this one, where medications with similar names are
confused, are a relatively common type of medication error. In the
early 2000s, Food and Drug Administration (FDA) acknowledged
this issue by creating a list of medications with commonly confused
names, for which the agency recommends using mixed case " tall
man " lettering to make it easier for providers to differentiate when
reading the label. For example, FDA recommends the drugs cisplatin
and carboplatin be printed as CISplatin and CARBOplatin. ISMP
has also recommended strategies to help prevent medication errors
involving similarly named medications, including using both
the brand and generic names on prescriptions and labels, adding
the purpose of the medication on prescriptions, and configuring
computer selection screens to prevent look-alike names from
appearing consecutively. ISMP also suggests changing the appearance
of look-alike product names to draw attention to their dissimilarities.
Some States Support Just Culture Ideas Through
Adverse Event Reporting Systems
Several states have taken steps to support just culture. For example,
since 2003, Oregon has supported the Oregon Patient Safety
Commission (OPSC), a semi-independent state agency that collects
data related to medical harm and shares it with providers to help
prevent future errors of a similar nature. OPSC currently performs
this duty through two channels. The first is the Patient Safety
Reporting Program (PSRP), which has operated since 2003. PSRP
aims to reduce the risk of serious adverse events occurring in Oregon's
health care system and encourage patient safety. The second is the
Early Discussion and Resolution system, which, since 2013, has
helped connect patients who experience harm with their health care
providers to facilitate candid discussions about what occurred, work
toward reconciliation, and contribute to safeguarding others from
harm. In addition, OPSC provides tools and best practice resources
through its website, both of which are intended to help health care
organizations create a culture of safer care.
NABP Supports a Just Culture Approach
Recognizing how a just culture approach may help to improve
patient safety and support the boards of pharmacy in their shared
mission of protecting public health, NABP has taken several steps in
support of improving pharmacist workplace safety and well-being.
At the 117th
NABP Annual Meeting, a resolution was approved
that acknowledged several important realities. These realities
8 | MAY 2023
include that the purpose of pharmacy practice is to ensure patients
receive appropriate care, are protected from potentially dangerous
medications, and that medication errors that cause patient harm
are a well-documented problem in the US. The resolution also
authorized the creation of the Task Force on Safety-Sensitive
Measures to Review Medication Errors.
When it convened in October 2021, the task force issued two
recommendations to help the boards of pharmacy in building a
safety-based culture for pharmacists:
1. Creating a medication safety academy.
2. Establishing educational workshops and materials.
In a policy statement issued in 2022, NABP expressed support
for just culture, particularly considering the coronavirus disease
2019 pandemic and its aftermath. The statement highlighted the
steps the boards of pharmacy and pharmacy associations are taking
to address these issues, such as the development of the Pharmacist's
Fundamental Responsibilities and Rights document created by the
American Pharmacists Association and the National Alliance of
State Pharmacy Associations.
In March 2023, NABP held its first Medication Safety Academy
meeting. Designed for board of pharmacy executive officers at
all experience levels, the two-day event featured discussions on
preventing medication errors, implementing continuous quality
improvement programs, and applying a just culture approach
to increase patient safety. In addition, NABP has offered and
promoted several educational workshops and other resources aimed
to help attendees improve workplace safety.
NABP has also continued to take action through its task
forces and committee meetings. In 2022, the members of the
Work Group on Workplace Safety, Well-Being, and Working
Conditions issued five recommendations to support a healthy work
environment to promote patient safety. One included expanding
the role of pharmacy technicians so that pharmacists can be more
available to perform duties within their skill set. Another endorsed
standardizing lunch breaks and shift lengths; yet another called for
utilizing more automation technology.
Medication errors are a significant concern in pharmacy and
health care as a whole. NABP will continue to take crucial steps
to address this issue, and to help promote a better working
environment for pharmacists and technicians at all levels.


Table of Contents for the Digital Edition of Innovations-Magazine-May-2023

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