R.Ph.s' take on patient safety: They're caught in the middle

July 25, 2005

Pharmacists play a critical role in ensuring patient safety. They detect and report medication errors, counsel patients, and educate other healthcare personnel. But two common communication problems?lack of a shared definition of error and of agreement as to the role and scope of the pharmacist's work?coupled with inadequate access to resources for managing the pharmacy workload prevent R.Ph.s from fulfilling their key role.

Pharmacists play a critical role in ensuring patient safety. They detect and report medication errors, counsel patients, and educate other healthcare personnel. But two common communication problems-lack of a shared definition of error and of agreement as to the role and scope of the pharmacist's work-coupled with inadequate access to resources for managing the pharmacy workload prevent R.Ph.s from fulfilling their key role.

We have come to this conclusion based on research we conducted. Our study was supported by the Agency for Healthcare Research & Quality and involved three surveys and multiple interviews of nurses, physicians, pharmacists, and administrators who work in 30 hospitals in nine states in the rural West. Participants completed three surveys, participated in key interviews, and analyzed biweekly case studies.

Our study found that 40% of the pharmacists who responded to our survey reported a lack of agreement among healthcare providers about what constitutes an error. This was clarified, during interviews, when R.Ph.s explained that they routinely intercept medication orders for incorrect drugs or dosages that are not regarded as "errors" since they did not reach a patient. And even when problems did reach the patient, as was the case when a patient was prescribed more than 20 different drugs from a single provider-some of which were contraindicated-the orders were viewed as "poor medical practice" rather than errors.

These insights may help explain why a vast majority of pharmacists (84%) indicated that certain types of errors keep recurring and it is not always clear what one should do. For example, when encountering medication orders that require adjustments in the dose or drug, some R.Ph.s contact the ordering physicians, some report that their hospitals have created protocols allowing them to make changes without recontacting the physician, and others said they adjust the order and note the changes on the patient charts.

Still others report more circuitous processes, such as: "I went ahead and fixed it because I wasn't going to take No for an answer anyway." Thus, as one pharmacist observed: "We have errors that go unreported, and we don't fix the problem." These experiences may explain why most pharmacists (84%) report that hospital staff have been trained in the error-reporting system, but also note (64%) that the error data from their hospital are not accurate.

Most R.Ph.s believe they have a personal impact on patient safety, rating their ability to make health care safer in their hospital relatively high (average rating of 7.3 on a scale of 1-10). They believe they should educate themselves (100%) and others (96%), act as role models (92%), make recommendations for procedure and policy changes (96%), and review reported events (92%).

Finally, most pharmacists want to receive information about patient safety such as summaries of error events (100%) or changes in procedures (96%). But hospital protocols can complicate this agenda. Some R.Ph.s see the patient's chart, some do not. Some pharmacists know the patient's diagnosis, but others do not. Some R.Ph.s know all the Rxs a patient is taking, others do not.

Even when adequate information is available, professional issues can limit the role and scope of R.Ph.s' work. As one pharmacist noted, problems with the management of warfarin could be reduced if the hospital pharmacy established a Coumadin clinic. Local physicians, however, resisted this shift of responsibility, and administrators
balked at interventions that could alienate physicians. Other R.Ph.s reported resistance when promoting use of clinical guides or protocols. Complained one pharmacist: "I have a physician with whom I've discussed dosing of pseudoephedrine for children many times. He almost always doubles doses."