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Patient Safety Is Primary Job for Missouri Pharmacist

Donna Young

Patient safety specialists like Nancy Kimmel, a pharmacist with Missouri Baptist Medical Center in St. Louis, are part of a new trend that has grown more popular with health systems since the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) adopted standards in July 2001 that included the implementation of patient safety programs.

JCAHO began surveying accredited health care organizations in January about their implementation of patient safety goals set by the accrediting body in July 2002. The goals call for eliminating wrong-site, wrong-patient, and wrong-procedure surgeries and improving the accuracy of patient identification, effectiveness of clinical alarm systems and communication among caregivers, and the safety of using infusion pumps and “high-alert” medications.

KimmelKimmel said she is one of the first people in the St. Louis area to hold the position of patient safety specialist.

At least one other hospital in Kimmel’s health system—BJC Healthcare, a 13-hospital health system in Missouri and Illinois—is recruiting a pharmacist to serve as a patient safety specialist, she added.

Missouri Baptist has shared its patient safety specialist job description with another midwestern health system, Sisters of St. Mary Health Care, which is also recruiting a pharmacist for the position, Kimmel said.

“They see the value of having a pharmacist in that role,” she said.

The two organizations have met at least twice to discuss patient safety issues and are considering an ongoing collaboration, she noted.

“There is a lot of competition between hospitals, but we have decided that patient safety is not something to compete about. So we are collaborating with other health care organizations outside our own,” she said.

The job. The National Patient Safety Foundation, a nonprofit research and education organization based in Chicago, Illinois, lists at least four different job descriptions with varying titles on its Web site for patient safety specialists.

David Shulkin, chief quality officer at Drexel University College of Medicine in Philadelphia, Pennsylvania, and president of the Patient Safety Officer Society (PSOS), said about 20% of the organization’s 500 members are pharmacists. About 25% of PSOS’s members are physicians, and the other 55% are nurses or quality improvement managers who, Shulkin said, generally have nursing backgrounds.

“There are an increasing number of pharmacists taking on these types of roles,” he said. “Pharmacists have had more experience with patient safety and medical and medication error reporting.”

The patient safety specialist is a relatively new job concept for many hospitals, noted Shulkin, who founded PSOS in June 2002.

But some states, including California and Pennsylvania, have regulations requiring hospitals to have someone coordinating and responding to patient safety issues.

Kimmel said that, while her job responsibilities include a strong focus on medication safety issues, she concentrates on other patient safety concerns, such as wrong-site surgeries and wrong diagnoses based on poor pathology.

Some health systems with patient safety specialists have an additional person serving as a medication safety specialist, Kimmel said, but she serves in both roles.

“But my role has gotten so huge that I am now recruiting for an assistant,” she said.

The assistant’s position will be filled by a pharmacy technician—“a career advancement” for pharmacy technicians at her hospital, she said.

Patient safety programs. As part of her job, Kimmel and one of the hospital’s executive administrators spend an hour meeting with staff from one unit per week for confidential one-on-one conversations about patient safety issues.

The conversations provide staff an opportunity to discuss concerns or report an adverse event or a near miss, the narrow avoidance of an adverse event.

Missouri Baptist also has a patient safety telephone hotline for staff and patients to anonymously report problems and concerns, Kimmel noted.

The hospital shares the plans and actions it is taking to resolve patient safety issues in an electronic newsletter, “We Heard You, We Acted,” that is e-mailed each month to all staff members, she said. Each newsletter issue is also posted on various bulletin boards in the hospital where patients and their families can read it “so they can see the things we are working on,” she added.

Missouri Baptist Vice President and Chief Medical Officer Max Cohen, who Kimmel described as “very passionate and very dedicated to patient safety,” writes the newsletter.

When Missouri Baptist first began its patient safety program in 1996, Kimmel said, each department developed its own plan.

“We were all working in our own little silos,” she said.

But when Cohen joined the hospital in 1999, he initiated a “broad-scale policy of working together as one multidisciplinary team,” she added.

Blame-free culture. The hospital recognized that it needed to adopt a blame-free culture to increase error reporting, Kimmel said.

“We knew that if we wanted to make changes using accurate data, we had to get accurate data,” she added.

The hospital has initiated a “just accountability culture,” Kimmel said, in which “everyone is accountable for patient safety in our organization.”

For instance, she said, if a staff member did not follow a policy because he or she was trying to get something critical to a patient, but an adverse event occurred, the person involved would probably not be punished because he or she was acting in the best interest of the patient.

“We would go back and look at what happened and maybe change the policy or the process,” she said. “Our whole concept is to look at the process first and not the person.”

But if an adverse event occurred and the event could be attributed to a staff member who was under the influence of alcohol, that person would be held accountable and disciplinary action would more than likely be taken, Kimmel said.

The hospital has created an “unsafe acts grid,” she said, that helps managers and frontline supervisors assess events.

“The whole blame-free culture was difficult to get everyone on the same page and apply it exactly the same to every employee across the organization,” Kimmel said. “There were some people that still clearly looked at the person first and then looked at the event. Culture is hard to change. It’s not an easy transition.”

Feedback is an important element in creating an environment in which staff can feel comfortable reporting errors, Kimmel said.

“You have to be able to say ‘I heard you and this is what you are telling me,’” she said.

Missouri Baptist has increased its error reporting 10-fold and Kimmel now gets 1000 near miss reports a month, she said.

“The downside is, we are still struggling with how to manage all the information,” she said. “It’s a challenge.”

Including patients. As part of the hospital’s patient safety culture change, Kimmel added, patients have been invited to participate in committees, including Missouri Baptist’s patient safety council.

The hospital has also created a patient-oriented medication safety education program, including a brochure that describes how to manage medication regimens.

The brochure has a “tear-off” wallet-sized card called “Mind Your Meds” on which patients can document medication information and have it easily available when they visit a physician, pharmacy, or hospital, Kimmel said.

Missouri Baptist has distributed over 75,000 of the cards to patients, she added.

Kimmel said several hospitals across the United States have replicated the “Mind your Meds” card, which she designed in May 2001.

“We feel very strongly that, as a nation, if we are going to do better in health care, we need to work together and share good ideas,” said Kimmel, who was recently named to the Patient Safety Leadership Fellowship, a program sponsored by the American Hospital Association and the National Patient Safety Foundation.

To help pharmacists become medication and patient safety specialists, Kimmel said, her hospital has incorporated medication safety as a focus of its pharmacy practice residency program’s rotation in general medicine.

Residents in the program will spend time with Kimmel learning how to address medication and patient safety issues.