HOSPITAL PRACTICE

Med errors: Don't overlook the people part of the equation

On a Sunday morning, a pharmacist in the Southeast mistakenly dispensed an adult dose of a narcotic medication for a child. It proved to be a fatal error. Investigation revealed that the pharmacist was on the job that morning just a few days after his wife had passed away.

"Do you think that pharmacist might have had other things on his mind? What was he doing at work on a Sunday morning so soon after burying his wife? What kind of bereavement policy did his employer have?" Anthony F. Grasha, Ph.D., posed these questions in focusing on the "human factors" in medication errors. His basic but often overlooked message: In building a system to minimize and prevent medication errors, don't forget the people part of the equation.

Grasha, professor of psychology at the University of Cincinnati, was the lead-off speaker in the Medication-Use Safety Learning Community at the Summer Meeting of the ASHP in Baltimore. This learning community was a collaborative effort between ASHP and the Institute for Safe Medication Practices (ISMP). It was one of four learning communities at ASHP, which thoroughly restructured its traditional CE schedule to allow in-depth exploration of the designated topic areas over several days.

"In our research, we take a close look at what else was going on at the time mistakes were made," Grasha said. "Often, we find that the pharmacist was fatigued, distracted, or emotionally tense.

"Fatigue," he continued, "is like having a .10 blood alcohol level. Also, it's important to keep in mind that 20% to 30% of stress on the job comes from personal and family concerns. In one case we reviewed, a pharma- cist who erred in filling a prescrip- tion said she'd been worrying because her kids were away on a camping trip and a storm was coming in."

Grasha advised managers to "be careful with people who have 'complicated lives.' They have a tendency to bring those lives to work." In fact, he noted later in an interview with Drug Topics, psychosocial factors may play a role in as many as one-third of medication errors. "This is true in all jobs," he said. "But pharmacists have a tendency to think that because they're professionals, they can leave these problems at the door. It isn't that easy.

"My basic message is that you can't afford to ignore these considerations. If there's a problem affecting an employee's performance, you need to talk it out and make use of options such as employee assistance programs." Grasha has developed a checklist of more than 100 human factors that influence medication safety; for details, you can reach him at Tony.Grasha@UC.edu.

Grasha encouraged his audience to build a NEST in the workplace, based on Nurturance, Empowerment, Structure, and Teamwork.

• Nurturance. "Employees want to feel important," Grasha said, "and they want to know you care. When job satisfaction goes up, error rates go down and productivity improves. When people come under stress and tension, they tend to revert to less efficient habits and take shortcuts."

• Empowerment. Performance may slip when supervisors do not encourage autonomy and show respect. "Employees want recognition, and satisfied employees treat other people better," Grasha emphasized. "If people feel abused within the system, they'll take it out on patients. This is true of physicians, it's true of nurses, and it's true of pharmacists." Low error detection and reporting are also more likely if supervisors have an "in-your-face" management style, fail to establish a climate for excellence and professionalism, and don't give reasons for why something is needed.

• Structure. Within a system that encourages autonomy, professionals also want to know clearly what's expected of them. "People respond to norms that are put in place in an organization and enforced and encouraged," Grasha said. Mistakes occur when explicit rules and procedures either are not available or are improperly applied.

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