14 Clinical
Pharmacy Practice News • July 2022
ASHP Meeting
Med Errors Communication Preserves Patient Trust page about what to tell patients and families about the error. As such, it’s important that all front-line clinicians receive some training in communication about harm events.
By Karen Blum
Phoenix—Effective communication with patients and their family members is a critical but uncomfortable step that pharmacists and other care team members must take after a harm event. Done well, it can preserve trust in the healthcare system and potentially reduce clinician stress and legal or disciplinary actions, speakers said at the 2022 ASHP Summer Meetings and Exhibition. Communication and resolution programs (CRPs)—principled, comprehensive, systematic and compassionate programs for preventing and responding to harm events—are an emerging best practice, said Thomas H. Gallagher, MD, MACP, a professor and an associate chair of the Department of Medicine at the University of Washington, in Seattle. “In healthcare, all of us aspire to be open and honest with patients and families when there’s been a problem,” said Dr. Gallagher, also the director of the UW Medicine Center for Scholarship in Patient Care Quality and Safety. “It’s certainly what we would expect as patients. But there are all sorts of reflexes and challenges that get in the way of turning that principle into practice.” CRPs should involve several elements, he said, including immediate reporting of an incident by clinicians and ongoing transparent communication with patients and families. Events should be thoroughly analyzed and used for quality improvement. For the subset of harm events that occur because of error or system failure, health-system personnel
Truthful and Transparent
should make CRPs a proactive offer of financial resolution rather than waiting for them to file a malpractice claim. These efforts shouldn’t just be focused on patient and family members, the speakers stressed: Involved caregivers also should immediately be offered some type of care or peer support.
Error Fallout Goes ‘On and On’ Patient and family advocates hate the term “resolution,” Dr. Gallagher noted, because for many of them, the events are never over. “They go on and on and affect multiple members of the family,” he said. “So, the notion that we’ve written a check, or we fix some little system problem, … that’s not at all how it works for the patients and families.” The benefits of CRPs, when done well, are several, he added. They preserve trust and meet patient/family expectations, reduce clinical distress, reduce the likelihood of litigation or of disciplinary action by regulators, promote learning
within and across institutions, strengthen institutional culture and climate, and increase the public’s trust in healthcare. A big challenge, however, is that organizations use CRPs inconsistently, applying them to some cases but not others, Dr. Gallagher said. Health systems might use the full approach for some cases or just some elements, such as telling a family what happened or what they plan to do to prevent recurrences, and then assume if a patient’s family is interested in financial compensation, they can just ask. “That’s not consistent with having a highly reliable CRP,” he said. The way organizations respond initially to harm events is “absolutely critical,” he said. “Oftentimes we just want to go in and tell them what happened, and then run out of the room,” Dr. Gallagher said. “That’s not the approach we want to take. We want to hear what’s on their mind and give them timely responses.” The work is a team effort, he added, with everyone needing to be on the same
Pharmacist JC Surveyor a Benefit to NCCN By PPN Staff
Phoenix—The Joint Commission’s addition of a pharmacist to the survey process for certain healthcare facilities has added a new level of expertise and insight to the review of standards compliance for medication-related processes, two leaders of the group announced at the 2022 ASHP Summer Meetings and Exhibition. Only healthcare organizations that are registered with the National Comprehensive Cancer Network (NCCN) are subject to surveys staffed by a pharmacist, according to a Joint Commission spokesperson. The decision to add the pharmacist surveyor “is a game changer,” said Jeannell Mansur, PharmD, the principal consultant, medication management and safety, Joint Commission Resources. The expertise of the pharmacist surveyor should reap many benefits, she noted, given the significance that medication processes
play in patient safety. As for why the pharmacist surveyor initiative is limited to NCCN hospitals, a Joint Commission spokesperson noted that the program “was the result of strong collaboration with the NCCN and their member organizations to better support our collective missions. As the Joint Commission continues to monitor this initiative, next steps will be determined.” One challenging area that has come up during surveys is complex medication orders, Dr. Mansur noted. To ensure compliance with these medication orders, pharmacists should review policies to ensure they include the required elements for titration, range, taper and other orders for which the Joint Commission requires hospitals to maintain policies, she said. Dr. Mansur pointed to block charting as one allowance that the Joint
Commission has published for titration orders. Block charting allows for more abbreviated documentation during urgent situations when titration medications are used, but which should not extend beyond four hours, she explained. Dr. Mansur added that the Joint Commission does not prohibit the adjustment of a titration infusion dose once the patient has met the titration end points. She also noted that the group does not require titration end points to maintain a maximum and a minimum.
Another Valued Team Member Besides adding a pharmacist surveyor, Dr. Mansur underscored the important role played by a different pharmacist on the Joint Commission team: co-presenter Robert Campbell, PharmD, the director of the Joint Commission’s Standard Interpretation Group. With his pharmacy
Being truthful and transparent about harms or medical errors as soon as possible is important not just for the families but also for practitioners, commented Natasha Nicol, PharmD, FASHP, moderator for the session and the director of global patient safety affairs at Cardinal Health in Houston. She speaks from experience, having been part of a team involved in a medication error years ago that resulted in the death of a 2-year-old girl. Silence, or an attitude of keeping errors quiet or thinking what families don’t know won’t hurt them, “is so much more damaging to a practitioner in moving forward and being able to stay in the profession,” Dr. Nicol said. “We really need to learn how to communicate effectively when events happen…It’s really about doing the right thing, and at the end of the day knowing that something really terrible happened but we gave the dignity and respect that people deserve.” It’s crucial to communicate with families throughout the process of reporting and analyzing events, she added. You don’t have to wait to have all of the information before disclosing a harm event to families. Drs. Gallagher and Nicol reported no relevant financial disclosures.
representation, there is a better understanding of hospital medication issues within the Joint Commission, Dr. Mansur noted, adding: “I have seen medicationrelated issues get addressed more timely” due to his involvement. “We receive a lot of medication-related frequently asked questions for which the Joint Commission provides direction.” As for his own take on what health systems should expect during surveys, Dr. Campbell stressed that medication management—although critically important—isn’t the only compliance area on which to focus. Regulations from the Occupational Safety and Health Administration (OSHA), for example, prohibit food and drink in areas exposed to blood and infectious or toxic materials. “[OSHA doesn’t] want to see you with one hand in a chest cavity and another eating a banana,” Dr. Campbell quipped. The sources reported no relevant financial disclosures.
