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The patient safety standards adopted by the Joint Commission on Accreditation of Healthcare Organizations recommend that hospitals appoint a patient safety coordinator to oversee the facility’s safety program. Now the American Society of Health-System Pharmacists (ASHP) in Bethesda, MD, has begun an initiative to develop and expand a professional category called "medication safety officer."
This position is a good fit with the Joint Commission’s patient safety standards, says Kasey K. Thompson, PharmD, director of ASHP’s Center on Patient Safety. The complexity of the medication use process, which involves between 80 and 180 distinct steps, warrants the need for someone to oversee the process’ safety and quality. The ultimate goal of the multi-phase initiative is to show how this type of pharmacy professional can significantly improve safety and quality in health systems. Thompson explains. The initiative was conceptualized in 1994, but just received funding last year.
"The whole issue of designing fail-safe medication use systems has been a major one in our organization for nearly 50 years," he says. ASHP knew that hospitals and health systems would be well-served to have someone oversee the aspects of safety and quality in the medication use process. "We also recognize that a good percentage of preventable adverse drug events or errors occur in [that] process. That led us in the last year to start asking the question, Are others out there doing this?’"
In the search to answer that question, the ASHP Center on Patient Safety contacted a number of hospitals and found people who were by title "medication use safety coordinators" or "medication use safety officers." "We asked what they were doing, in essence to send us their job descriptions," Thompson says. The center didn’t find a lot of consistency in job responsibilities. "We didn’t see a lot of what we thought should be done based on best practice’ and current scientific evidence. We did see some of it being done in various places."
The ASHP Research and Education Foundation then funded the center to do a systematic task analysis. Researchers traveled to a number of hospitals that ASHP had pre-identified as having individuals performing this role. "We tried to pick places that were doing various things, but not all the same things, so we could do a good systematic task analysis and determine what the roles and responsibilities should be for a medication safety officer," Thompson says.
The researchers returned with a stack of paper that had a series of roles and responsibilities identified by the systematic task analysis. Next, the center asked a design team — comprising pharmacists, physicians, human factor specialists, and epidemiologists — to look at the findings and see what seemed right and what gaps needed to be filled. "They also did a learning analysis to determine what it would take for someone to learn what they needed to know to perform these duties," Thompson says. The task analysis currently is out for external review so the center can get feedback on the documents.
Out of these analyses, the center expects to get a well-defined job description of the roles and responsibilities of a hospital or health system medication safety officer. This job description, which the center expects to release to the public by October, will give hospitals and health systems a tool for creating the position. The completed job description also will end the first phase of the initiative.
The next phase involves putting into practice the findings from the first phase and then conducting research on the results, Thompson explains. To accomplish this, the center will take pharmacists who currently are practicing and place them in hospitals or health systems to perform the roles and responsibilities detailed in the job description.
"We want to study their impact on patient safety and whether there is any effect in having a health system medication safety officer," Thompson says. "Having scientific evidence provides a platform to say that this is so important that every hospital in the country should have someone performing this role."
The center also will provide educational tools to supplement the job description. "We’ll develop educational programs, residencies, accreditation standards, and other tools to help people become competent as safety officer." These last two phases will play out over upcoming months and years, Thompson adds. "It is a long-term project."