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PSOS is a new organization formed to enhance patient safety
Following the 1999 Institute of Medicine report on patient safety, many states passed legislation designed to curb medical errors. In 2001, 22 states passed laws to ensure higher levels of patient safety. In 2002, 64 pieces of such legislation are expected to surface.
An example of the types of bills being passed is the recent signing of landmark legislation in Pennsylvania by Gov. Mark Schweiker. The Medical Care Availability & Reduction of Error Act requires hospitals to submit a patient safety plan, including the designation of a patient safety officer (PSO), to the state department of health by July 18.
With heavy pressure to reform their system, many hospitals have appointed PSOs. These individuals are responsible for reporting medical adverse events and studying solutions to overcome identified problem areas. To effectively do this, one needs to understand where the hospital is vulnerable and enact systems to prevent future errors.
A new group, the Patient Safety Officer Society (PSOS), was officially launched on June 1 to address the needs of those suddenly finding themselves in this new role. David Bernard, M.D., executive v.p. and chief medical officer for DoctorQuality Inc., said the society was started because of "a need to focus on common issues, to learn from one another, and share common experiences."
David Shulkin, M.D., president of PSOS, said, "Our focus will be to lead change efforts, fighting against problems for decades to come." Although PSOS is new, it already boasts 250 members from all over the world. About 25% of its members are pharmacists.
"Medical errors most commonly result from clinical or administrative mistakes," said Bernard. He cited such mistakes as leaving a sponge inside a body cavity after surgery or operating on the wrong body part as examples of clinical errors. Administrative errors include mishaps like failing to put a bed rail up and having a patient fall out of bed or X-raying the wrong patient. Interestingly, drug errors constitute a small piece of the medical-error pieaccounting for only 35% of all med errors.
Pharmacists who are appointed to PSO positions often assume the roles of medication safety specialists. Colleen Malashock, Pharm.D., medication safety specialist with the Nebraska Health System, reported that her job primarily involves "getting medication-error reports within the institution, observing trends, and implementing plans to facilitate performance improvement."
When serious errorserrors that cause harm to patientsare reported, Malashock performs a root-cause analysis to determine where system breakdowns occurred. This information is then shared with the P&T committee, with the director of outcomes performance improvement, and with nursing units so that changes can be implemented.
Another medication safety pharmacist, Kelly Verzino, Pharm.D., BCPS, at DCH Regional Medical Center in Tuscaloosa, Ala., spends much of her time refining med-error reportingand does so using the MedMARx system. MedMARx is a data reporting system from the United States Pharmacopoeia that identifies four major error categories (potential for error, no harm, harm, or death). MedMARx supports systemic reporting, tracking, documentation, analysis, and sharing of med-error data among hospitals.
So far, using this system, Verzino has found, "Most of the errors have not resulted in harm to patients. The most common types of errors are those of omission [a dose not given] or drugs given at the wrong time." These types of errors are consistent with those most commonly reported at hospitals across the country, according to the recently released MedMARx 2000 Report.
Among other responsibilities, as medication safety specialist for Tampa General Health Center, Sarah Hein, Pharm.D., studies human factors that tend to cause errors. For example, Hein found that when R.Ph.s are flagged over and over by computer systems (e.g., drug allergies or interactions), they tend to ignore those warnings. She recently "fixed" such a problem by reprogramming the system to flag only items considered to be "highest risk." She uses a process referred to as "failure mode analysis" to ask, "With this process, where are the highest risks for errors reaching the patient?"
Hein has the opportunity to work with other departments throughout the hospital. Commenting on her job as a PSO, she said, "This is a position you grow into until it consumes you, and then they put you in charge of it, but it often feels as if no other people are doing it."
And that is precisely why membership in PSOS is growing so rapidly, Shulkin said, because it provides networking opportu-nities for PSOs, allowing them to expand upon their roles and unite as a collective voice to focus on common issues.
To find out more about the Patient Safety Officer Society (PSOS), visit its Web site at www.PSOS.org or e-mail the society at PatientSafetyOff@aol.com. Membership is free for patient safety officers.
Kelly Karpa. Patient safety officers: A newly emerging role for pharmacists. Drug Topics 2002;16:HSE24.