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Medication Safety Requires Team Effort

Kate Traynor

Ensuring patients' safety during each step in the medication-use process requires a team effort—and that team must include pharmacists, says Kasey K. Thompson, Pharm.D., director of ASHP’s Center on Patient Safety.

This conclusion, Thompson said, came out of the work of the design team assigned to ASHP’s "Medication Safety Officer" initiative, which was launched last June through a grant from the ASHP Research and Education Foundation.

Thompson said ASHP began studying the concept of a medication safety officer—a person charged with overseeing the safety of a hospital's entire medication-use process—in the early 1990s, long before the Institute of Medicine’s 1999 report "To Err Is Human: Building a Safer Health System" brought medical errors into the national spotlight.

"The landscape changed" after release of that report, he said, and all health care providers and organizations had to publicly commit to reducing medical errors.

During the first phase of ASHP's initiative, Thompson said, the design team collected job descriptions from health systems in which people had been assigned to a position similar to a medication safety officer. Design team members also visited work sites and observed the day-to-day duties of medication safety officers.

After collecting what Thompson described as "a rather large amount of data and information," the design team pinpointed the most critical components of a medication safety officer’s role and distilled these duties into a job description.

Although some health systems involved in the analysis were doing "an excellent job" covering some of the critical components, the design team found that "no one was doing everything that needed to be done in a systematic fashion," Thompson said.

The product of the design team’s work, a "task analysis" (PDF), describes 33 essential roles and numerous related duties that should be addressed by "medication-use-safety teams" in health systems. Areas for which the teams are responsible include standardization, storage, and labeling of medications; staff competency and education; patient education; risk management; and communication of medication orders.

According to the task analysis, medication-use-safety teams should include "at least one pharmacist, one nurse, and one physician."

"This is not the job of one person," Thompson emphasized. "It really is the work of a team."

Thompson said that a critical characteristic of a medication-use-safety team is that members "must be front-line practitioners who are involved in a meaningful way and have a thorough understanding of the medication-use process." He said ASHP envisions that the team members will be professionals who can incorporate additional education and training with the insight gained from years of practice to make the medication-use process safer.

He pointed out that the delivery of medications to patients in health systems involves at least 80 distinct steps and may take as many as 200. "Mistakes can occur at every one of these steps," he said.

Thompson said ASHP’s next step is to develop training programs for medication-use-safety coordinators.