Teaching of Patient Safety in Pharmacy Curriculum

Dr. Bhaswat S Chakraborty Sr. Vice President & Chair – R&D Core Committee

Cadila Pharmaceuticals Ltd

Presented at the 3rd Annual Conference of SPER at Lovely Professional University, Punjab, India, March 8, 2014

Pharmacy Practice

• Academia, Research• Industry• Community• Hospital• Regulatory• Long term care• …

All need to be concerned with patient safety

Examples of Public Safety Initiatives (USA)

• NTSB – Evolution of the Air Commerce Act of 1926

• 1938 Food Drug and Cosmetic Act

• OSHA – Occupational Safety and Health Act of 1970

• Departments of Public Safety (fire, rescue, ambulance, police etc.)

• Homeland Security Act of 2002

All countries have such legislation

AuthorsLinda T. Kohn, Janet M. Corrigan, and Molla S. Donaldson, Editors; Committee on Quality of Health Care in America, Institute of Medicine

Description•Experts estimate that as many as 98,000 people die in any given year from medical errors that occur in hospitals. •That's more than die from motor vehicle accidents, breast cancer, and AIDS•Financial cost to the human tragedy, and medical error easily rises to the top ranks of urgent, widespread public problems.

Context

To Err is Human:Building a Safer Health System

• This book was the first report within a larger project (Quality of Healthcare in America)

• Developed by 38-person committee• Rationale:

– Immense burden of harm– Preventable and shouldn’t happen– Understandable concept by Americans– Sizeable evidence base– Healthcare system is rapidly evolving

Probably this was not expected of a health care system

To Err is Human:Building a Safer Health System

Major Recommendations (National Agenda):• Center for Patient Safety within AHRQ

• Nationwide mandatory reporting system (death/serious harm) and encourage voluntary reporting of all errors

• Peer-review protections to data

• Performance standards and expectations

• Safe use of drugs (pre and post marketing)

• Priority for organizations and professionals

To Err is Human:Building a Safer Health System

“ A major force for improving patient safety is the intrinsic motivation of healthcare providers, shaped by professional ethics, norms and expectations”

• Definitions:– Safety – Freedom from accidental injury

– Error – Failure of a planned action to be completed as intended OR use of a wrong plan to achieve an aim

– Harm – any negative outcome

Three Reporting Categories

• Incident: Any unintended or unexpected incident which could have, or did, lead to harm for one or more patients

• Near miss or Close call: An event or situation that did not produce patient injury, but only because of chance

• Unsafe condition: Unsatisfactory physical condition existing in the workplace environment immediately prior to an incident or event

All three categories must be attended

High-Reliability Organizations (HROs)• Operate in hazardous conditions and have fewer

than expected adverse events• Examples:

– air traffic control, nuclear power plants, aircraft carriers.

• Common Key Features– Preoccupation with failure– Sensitivity to operations– Culture of safety

All HROs have characteristic hazard minimization approach

National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP)

• Four categories of reporting– Error– Error, No harm– Error, Harm– Error, Death

Probably this was not expected of a health care system

National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP)

Components of Any Culture

• Values• Attitudes• Norms• Beliefs

• Practices• Policies• Behaviors

The way we do business around here

Culture of SafetyKey Features:• Acknowledge high-risk nature• Achieve consistently safe operations• Promote blame-free environment that encourages

the reporting of errors and near misses• Employ collaboration (ranks/disciplines) to seek

solutions to safety problems• Organizational commitment of necessary resources

Measuring Safety ClimateElements Commonly Measured:• Easy to learn from mistakes• Errors are handled appropriately• Clinical leaders listen to me and care about my

concerns• Leadership is safety-driven• My suggestions are acted upon• I am encouraged to report safety concerns• I know proper administrative channels

Mistakes are not ignored rather learned from

Why Patient Safety Education for Pharmacists?

• Health care system is an enormous bliss to humanity and yet there are horrific errors and system failures

• All health-care students, including Pharmacists, must prepare themselves to practise safe care

• Patient safety knowledge applies to all areas of practice• Pharmacists need to know and manage

– how systems impact on the quality and safety of health care– how poor communication can lead to AEs – More...

• Patient safety is not a traditional stand-alone discipline; rather, it is one that integrates into all areas of health care

Pharmacist provide multi-level resistance to errors & harms

How were WHO CurriculumGuide topics selected?

• The Curriculum Guide covers 11 topics• A lot came from Australian and Canadian experiences• Three main stages were used in the development of the Framework

content and structure– initial review of knowledge and development of framework outline– additional searching for content and assignment of knowledge, skills,

behaviours and attitudes– development of performance-based format

• The Canadian approach provides an interprofessional, practical and useful patient safety framework– using knowledge, skills, and attitudes required by all health-care

professionals

The Canadian Frameworkof Safety Competencies

Source: The Safety Competencies, Canadian Patient Safety Institute, 2009

The WHO Curriculum Guide Topics1. What is patient safety?2. Why applying human factors is important for patient safety3. Understanding systems and the effect of complexity on patient care4. Being an effective team player5. Learning from errors to prevent harm6. Understanding and managing clinical risk7. Using quality-improvement methods to improve care8. Engaging with patients and carers9. Infection prevention and control10. Patient safety and invasive procedures11. Improving medication safety

The topics are taught over 4-5 curricular years

When and What to Teach

Integrating Patient Safety Education Into Health Professional Curricula

Source: M. Walton, Sydney School of Public Health, University of Sydney, Sydney, Australia, 2010

Skills Training• Communicating risk;• Asking permission;• Accepting refusal;• Being honest with patients;• Empowering patients–helping patients be active participants in

their own care;• Keeping patients and relatives informed;• Hand hygiene;• Patient-centred focus during history taking and appropriate

examinations;• Clinical reasoning–diagnostic error, consideration of risk benefit

ratio of procedures, investigations and management plans.

Skills are practiced over & over

Miller’s Triangle

Source: Miller GE. The assessment of clinical skills/competence/performance.AcademicMedicine,1990

Educational Principles• Main objective of any teaching is

to transfer the (classroom) learning to workplace

• Context is highly relevant

• Contextualize patient safety principles

• Use examples that are realistic for your setting

• Identify practical applications

• Use examples that are of interest or soon will be relevant to students

Case exampleWhile observing a surgical operation, a nursing student notices that the surgeon isclosing the wound and there is still a pack inside the patient. The student is not sure ifthe surgeon is aware of the pack and is wondering whether to speak up.

Right teaching will teach her to speak up in all such situations

Inspiration to do

Teaching Styles

• One authority identifies six important roles of the Teacher/Professor :– Information provider– Role model– Facilitator– Assessor– Planner– Resource producer

The WHO Curriculum Guide Topics

1. What is patient safety?2. Why applying human factors is important for patient safety3. Understanding systems and the effect of complexity on patient care4. Being an effective team player5. Learning from errors to prevent harm6. Understanding and managing clinical risk7. Using quality-improvement methods to improve care8. Engaging with patients and carers9. Infection prevention and control10. Patient safety and invasive procedures11. Improving medication safety

A patient safety model of health care Emmanuel et al 2008

1. What is patient safety?

Patient Safety

• Students should:– understand the multiple factors involved in

failures– avoid blaming– practise evidenced-based care– maintain continuity of care for patients– be aware of the importance of self-care– act ethically everyday

2. What is human factors?• The study of all the factors that make it easier to do the

work in the right way• Apply wherever humans work• also sometimes known as ergonomics• Examples

• order medications electronically• hand off information• move patients

If all of these tasks become easier for the health-careprovider, then patient safety can improve.

Optillusions.comAre the lines crooked or straight?

What is an error?

• The failure of a planned action to achieve its intended outcome

• A deviation between what was actually done and what should have been done

• Easier: “Doing the wrong thing when meaning to do the right thing.”

Situations associated with an increased risk of error

• unfamiliarity with the task*• inexperience*• shortage of time• inadequate checking• poor procedures

• poor human equipment interfaceVincent

* Especially if combined with lack of supervision

Stress and Performance

Stress level

Area of “optimum”

stress

Low stress Boredom

High stress Anxiety, panic

Pe

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Yerkes, R. M., & Dodson, J. D. (1908) The relation of strength of stimulus to rapidity of habit-formation.

Journal of Comparative Neurology and Psychology, 18, 459-482

2. Systems and Effect of Complexity on Patient Care

• The study of all the factors that make it easier to do the work in the right way

• Apply wherever humans work• also sometimes known as ergonomics• Examples

• order medications electronically• hand off information• move patients

If all of these tasks become easier for the health-careprovider, then patient safety can improve.

5. Learning from Errors to Prevent Harm

• Error: Doing the wrong thing when meaning to do the right thing

• Violation: A deliberate deviation from an accepted protocol or standard of care

• Incident monitoring: collecting and analysing information about any events that could have harmed or did harm anyone in the organization

• Incident monitoring: a fundamental component of an organization’s ability to learn from error

Error management is removing error traps by monitoring

Performance

Am I safe to work today?

Root Cause Analysis

• A rigorous, confidential approach to answering:

– What happened?

– Why did it happen? – What are we going to do to prevent it from happening

again? – How will we know that our actions improved patient

safety?

11. Improving Medication Safety

• Prescribing involves choosing an appropriate medication for a given clinical situation taking individual patient factors into account such as allergies

• selecting the administration route, dose, time and regimen• communicating details of the plan with:

– whoever will administer the medication (written-transcribing and/or verbal)

– and the patient

• documentation

How can Prescribing Go Wrong?• Inadequate knowledge about drug

indications and contraindications

• Ignoring individual patient factors e.g. allergies, pregnancy, co-morbidities, other medications

• Wrong patient, wrong dose, wrong time, wrong drug, wrong route

• Inadequate communication (written, verbal)

• Documentation - illegible, incomplete, ambiguous

• Mathematical error when calculating dosage

• Incorrect data entry when using computerized prescribing e.g. duplication, omission, wrong number

Look-a-like and Sound-a-like Medications

• Celebrex (an anti-inflammatory)• Cerebryx (an anticonvulsant)• Celexa (an antidepressant)

• Avoiding such confusion– know accepted local terminology– write neatly, print if necessary– avoid trailing zeros

• e.g. write 1 not 1.0

– use leading zeros • e.g. write 0.1 not .1

Finally, Pharmacovigilance

• Any curriculum in patient safety would be incomplete without teaching pharmacovigilance (PV)

• PV has emerged as a standalone course and a well practiced domain of patient safety all over the world

• PV involves – Monitoring, evaluation and implementation of drug safety– Detection and quantitation

• of adverse drug reactions (ADRs)• novel or partially known

– previously unknown– known hazard ↑frequency or ↑severity

• in their Clinical nature, Severity or Frequency

Conclusions• A huge body of evidence exists indicating that patients are not always

safe in the modern health care system

• Harm mainly comes from therapeutic failures, medication errors, neglect of patients, wrong dispensing, inadequate supply and also lack of education and good practices of care givers

• Teaching patients safety to health care students like doctors and pharmacists is one of the best approaches to mitigate some of the safety problems

• WHO curriculum guide for multi professionals is a very rich resource to address teaching and learning of patient safety

• Patient safety and Pharmacovigilance must be taught and integrated at both undergraduate and graduate levels of pharmacy educations

• All highly reliable organizations make sure that safety of the people that they serve comes first

Thank you Very Much

Acknowledgement: Ms. Raji Nair

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