Educating pharmacists, nurses and physicians in medication safety and evaluating their knowledge and skills in that area are vital if hospitals want to avoid the errors that seriously harm patients and drive up costs.
All too often, however, hospitals with other pressing needs push education and staff competency assessment to the back burner. The result, said Matthew Grissinger, RPh, the director of error reporting programs at the Institute for Safe Medication Practices (ISMP), in Horsham, Pa., is that they miss opportunities to enhance their patient safety strategies.
Speaking at a recent ISMP webinar, titled “Improving Medication Safety through Staff Education and Competency Assessment,” Mr. Grissinger described some of the problems the ISMP witnesses during hospital consult visits across the country. Competency assessments, he said, are frequently inconsistent throughout an organization. “Often,” he added, “we’ll see competency tests that are really calculation tests, and that’s it.”
Additionally, Mr. Grissinger said, ISMP often encounters a lack of standardized interdisciplinary education, “meaning education is very siloed—which is kind of odd because we’re expected to work as a team in our systems.” He also noted a lack of consistent credentialing, training and certification as well as a lack of information-sharing about errors that occur, their causes and ways to prevent future ones.
Supporting ISMP’s hospital-consult observations, Mr. Grissinger presented results from the group’s most recent Medication Safety Self-Assessment survey, encompassing responses from more than 1,300 organizations. The survey, which has been submitted for publication, uncovered spotty adherence to some of ISMP’s core characteristics of effective staff education and competency assessment.
Overall, Mr. Grissinger said, respondents achieved an average score of only 64% on questions designed to assess whether practitioners receive sufficient orientation on medication use; undergo baseline and annual competency evaluation of knowledge and skills related to safe medication practices; and whether they receive ongoing education on medication error prevention and the safe use of high-alert drugs.
Certain items produced particularly low scores (Figure). For example, in 34% of the respondents’ hospitals, new staff pharmacists undergoing orientation are not assigned to spend time in patient care units becoming familiar with drug prescribing practices, unit stock storage conditions, medication administration procedures and patient education practices. Additionally, nearly 72% of respondents noted that newly hired nurses do not spend time in the pharmacy or with clinical pharmacists during orientation.
Other low-scoring measures included whether pharmacists participate in the orientation of new medical staff and whether the organization provides formal teamwork planning. Nearly 47% of respondents said their hospitals don’t include pharmacists in medical staff orientation, and nearly 34% reported a lack of teamwork exercises.
A VA Hospital That
In contrast, some hospitals make it a point to build staff education and competency assessment into their daily routines. At the ISMP webinar, Alexander Reiss, MD, the chief of the Hospitalist Section at the James A. Haley Veterans Hospital and Clinics in Tampa, Fla., described a safety culture at the 548-bed VA facility that emphasizes a bottom-up, interdisciplinary approach to error prevention. “We have a morning report every day,” Dr. Reiss said, “and once a week we’ll spend about 15 minutes on just a quick topic on patient safety or quality. It’s often entertaining and very interactive, so no one gets too bored, and they learn a little bit along the way.”
Additionally, he said, the VA hospital’s regular morbidity and mortality conference, which “used to be about blame and shame and where did it go wrong and who is responsible,” now focuses on a “systems approach to medical errors—how can we find ways to prevent them and fix systems to work for us rather than against us.”
Dr. Reiss said one example of the VA hospital’s interprofessional approach is its medication tracer program. He described how an interdisciplinary group of 10 to 12 students, nurses, medical residents, staff pharmacists and others regularly gathers to learn about vulnerabilities in medication use by following an actual order through the entire process, from computerized prescriber order entry to the pharmacy to administration by a nurse at the bedside. The detailed walk-through takes about an hour, he said.
The group is asked to come up with solutions to the problems they spot, Dr. Reiss said. Typically, “they start with weak solutions, but eventually come up with some really strong solutions, environmental changes and infrastructure changes.” Dr. Reiss said that the process is “a very effective tool—a very interprofessional way to see where the problems exist within our system that we had no idea were even there.”
The safety group also schedules other interdisciplinary learning sessions, like the “environment of care” rounds, where a group visits a nursing unit room in which a patient has agreed to take part. “We just chat,” Dr. Reiss said. “We point out things in the room, and the patient invariably tells us things that we weren’t aware of or didn’t even think about. That’s probably the most eye-opening part, the interaction with the patient.”
Mr. Grissinger provided webinar participants with a number of suggestions for improving their organizations’ safe medication use education programs, including using communication logs to share safety tips in patient care areas; introducing videotapes and interactive CD-ROM programs; conducting simulation exercises; and scheduling weekly safety rounds with front-line staff and management.
Kyle Hultgren, PharmD, the managing director of the Center for Medication Safety Advancement at Purdue University, in West Lafayette, Ind., noted how challenging it can be to develop medication safety “standards inside of your hospital, let alone across the entire health system.” Part of the solution, he said, “comes down to defining a standard language. A lot of people have really excellent ideas, but how do we begin to discuss medication errors and improving medication use practices if we’re all speaking a different language?”
Still, making improvements “is certainly not impossible,” he said. “One of the things that ISMP does a great job in is stressing the notion of competency.” What they and other groups are trying to accomplish, he said, “is to create effective standards of care and make sure the people” adhere to them. And assessing competencies, he added, helps to ensure that standards are followed. Good standards don’t “script patient care,” Dr. Hultgren said, but they do ensure that when “it comes time to provide patient care, we can think at the top end of our licenses.”
Dr. Hultgren also pointed out that developing medication safety standards cannot be accomplished solely through a “top-down” process. “The parameters, the guidelines and the cultural tone have to be set by the leadership,” he said, “but from the bottom-up is where the improvements start to happen. It’s really a collaborative approach across the entire spectrum.”