September 6, 2023
By Stephanie Mason, PharmD, CDCES
Despite the healthcare industry’s increased focus on advancing health equity and improving patient safety, research has shown that one in four patients admitted to hospitals in the United States will experience harm during their stay (N Engl J Med 2023;388:142-153). The same study also revealed that medication-related errors are the leading cause of injury and avoidable harm in these events. While much of this harm has been attributed to COVID-19 pandemic–related challenges, inflationary pressures and labor shortages, the fact remains that the annual global cost associated with medication errors is approximately $42 billion. And that figure doesn’t include increased mortality rates and increased length of stay.
Optimizing patient care and reducing harmful events require a commitment from all levels of a health system, including executive leadership, management and front-line workers. Medication safety initiatives are the lynchpin of these efforts, and pharmacists have an opportunity to elevate their roles as medication experts to drive systemwide change. Their expertise, leadership and guidance are essential in fostering multidisciplinary collaboration, assessing existing processes and technologies, and developing and implementing modern approaches that can reduce medication errors.
Empower Pharmacy Teams to Spearhead Change
Pharmacists serve as medication experts and are well positioned to lead medication-related change initiatives, and pharmacy leaders should empower their teams to lead such efforts. This support could include supplemental education, additional training in quality improvement (QI) processes and communication of patient safety metrics. Pharmacy leaders also should guide their team members through the nuances of undertaking change management, such as how to identify key stakeholders, secure executive support and navigate an increasingly complex health system.
Establishing Multidisciplinary Medication Safety Efforts
Medication-use processes are integrated efforts that require collaboration among a wide range of professionals. Pharmacists can, for example, form a multidisciplinary subcommittee within their hospital’s pharmacy and therapeutics committee to explore insulin-related safety events that occur during subcutaneous administration to patients. The subcommittee—consisting of pharmacists, providers, specialists, informaticists and nurses—can review safety metrics, set a QI initiative to reduce the number of insulin-related administration errors and track QI data. That data can then be shared both with executive leaders as well as front-line care team members.
Review and Assess Existing Processes and Technologies
The best place for pharmacy teams to start with medication safety initiatives is to first evaluate how their existing processes and technologies are affecting patient safety. This will allow them to identify where preventable errors are either occurring or likely to occur in the medication-use process. Evaluating these processes and tracking relevant metrics can provide actionable insights that reveal where improvements are most needed. If a hospital is not tracking outcome or process metrics, this is the first place a pharmacy team should start. Without these data, it’s incredibly difficult to engage needed support for change initiatives and to track the impact of such initiatives.
Once areas of improvement have been identified, pharmacy teams can explore possible solutions. Technology has emerged as a key solution for pharmacy teams to reduce medication errors, and more are leveraging platforms and devices that provide the necessary data to measure success. According to the Institute for Safe Medication Practices, clinical decision support software is a high-leverage solution that hospitals should consider implementing to lower the number of medication-related errors from high-alert medications. These tools can reduce the burden on front-line care teams and improve patient safety by standardizing practices and optimizing workflows through electronic health record integrations.
Develop a Business Plan to Reduce Safety Events
While some medication safety efforts will be light administrative and operational lifts, others will require executive buy-in and a business plan to secure the necessary approvals. A great example of the latter is the adoption of clinical decision support software. In this example, the business plan should clearly and adequately communicate the current impact of medication errors on patient outcomes, institutional finances, and other key metrics and performance indicators. The business plan also should include the anticipated benefits of the software on patient outcomes, clinical workflows and cost reductions. Taking this approach in the business plan makes it easier for decision makers to consume the information and connect the proposal to organizational priorities.
In addition, the business plan should highlight the perspectives of clinical and technical resources that may be affected by the proposed change, such as pharmacists, providers, nurses, technicians and informaticists. Once the business plan has been approved, project managers must establish a regular cadence with executive leadership and the appropriate stakeholders to discuss potential and established obstacles, review performance metrics, and share wins.
Pharmacists Taking the Lead
Texas Health Huguley Hospital, a Centers for Medicare & Medicaid Services Five-Star facility offering advanced inpatient diabetes care to patients in Fort Worth, successfully applied this pharmacy-led approach within its Diabetes Center of Excellence. The facility’s critical care glycemic management program was inconsistent and lacked clearly defined roles, which frustrated clinicians and ultimately led to worse outcomes for patients. After empowering the pharmacy team to foster collaboration across the system, establish key performance indicators to measure success, and implement changes to existing processes and software, Texas Health Huguley brought efficiency to an extremely complicated process. This allowed pharmacists to grow clinically and most importantly, saw marked improvement in patient days with blood glucose target levels.
As patient safety organizations continue to take action and raise the standard of care for high-alert medications, health systems must act now to meet these guidelines and reduce medication errors. Pharmacists possess the necessary skill set to lead these changes, and they can leverage their expertise to improve medication management and the medication-use process, implement new technologies, and establish safety committees that will result in lifesaving improvements.
Dr. Mason is a diabetes clinical pharmacist at Glytec.