Going back to school for patient safety is something we should routinely do. It should come as no surprise that the biggest threats to patient safety are also the items we take for granted. As the kids head back to school to take on new challenges, we should challenge ourselves to renew our focus on enhancing patient safety.

You could probably easily name five common patient safety issues. The list is long, and we work hard at it every single day to minimize the risks. The items we will be focusing on today should not be surprising. In fact, some are very obvious.

What would you guess is the number one reason for patient harm? Surgical mistakes or healthcare associated infections, right? Wrong! According to the World Health Organization (WHO), the leading cause of injury and avoidable patient harm are medication errors. Adverse events because of unsafe care are one of the top ten leading causes of death and disability worldwide. Let that sink in for a second. Globally, the cost of medications errors is estimated to be forty-two billion dollars per year.

Let’s look at five common patient safety issues:

1. Medication management: There are many components to medication management and, unfortunately, this leads to many opportunities for patient risk and facility liability. It’s a fact that errors in medication management are a leading cause of malpractice claims. The best way to increase patient safety and reduce facility risks is to work with a highly qualified consultant pharmacist. In the facilities I serve, I perform comprehensive assessments of their medication management systems, including reviewing over one hundred different items with a relentless focus on patient safety and regulatory compliance. While it may be tempting to take this on yourself or hire just any pharmacist to do a basic audit, this is not a good idea. So much is at stake for your patients and for your organization. Medication management is not a good place to cut corners in an effort to save a few pennies. If you work with a good pharmacy consultant, not only will you protect your patients and your facility, but you will also recoup your investment, many times over, by avoiding just one patient incident. Not to mention how much you will save in liability and survey deficiencies!
2. Drug shortages: Drug shortages are happening with more frequency, leading to disruptions at the facility level. At times, it’s just an inconvenience, but sometimes it causes changes in operations and even temporary facility closures. The reasons for shortages range from simple delays through manufacturing issues that can lead to complete discontinuation of medications. Facilities usually struggle to stay ahead of the game, to get answers when shortages happen, and to find alternatives to allow for uninterrupted patient care. Your consultant pharmacist should be able to prepare you for drug shortages, keep you informed of the latest trends, and help you navigate problems that occur when alternatives are necessary (for further reading on this, please see a recent post on this blog, Ten Steps to Dealing with Drug Shortages).
3. COVID-19 and low vaccination rates: The ongoing pandemic and the struggle to increase COVID-19 vaccination rates also impacts patient safety. Not only is COVID-19 an infection control issue, but it has also severely strained the healthcare system and impacted patients in indirect ways. The recent focus has been on COVID-19 vaccines, but the disruptions in patient care because of limitations on office visits, as well as patients fearing going to their doctor’s office, has led to a decrease in the rates of other vaccinations. This puts patients at risk by reducing their protection to other diseases and ultimately increases everyone else’s risk too.
4. Infection control: It’s no surprise that the COVID-19 outbreak has drained healthcare resources and although everyone in healthcare is always thinking about infection control, the severity with which we have focused on COVID-19 is so large that it has forced many infection preventionist are spread too thin. What does this mean? It means that while we are so highly focused on the coronavirus, we are inadvertently letting some other things slip…it’s only natural. While infections preventionists focus on the acute care of patients, they have less time to dedicate to prevention activities. The old adage is true: an ounce of prevention is worth a pound of cure.
5. Compounding drugs: Does your facility use compounded drugs? If so, do you get them from an FDA registered 503B outsourcing facility? According to a 2019 report from the U.S. Department of Health and Human Services Office of Inspector General, about 11% of hospitals get compounded drugs from sources that are not registered with the FDA. This leads to increased risks to your patients and liability for your facility and staff. Take steps to protect your patients and let a consultant pharmacist help you do a proper assessment of any outsourcing facility prior to ordering products.

We know the list of patient safety risks is long and changes frequently. Enhancing patient safety requires constant vigilance and expertise. Each facility should have systems in place for ongoing assessments and quality improvement. Back to school time is a great time to reengage and redirect our focus on the greatest risks facing our patients. Being in the patient safety business is a never-ending task, but it is most definitely a team sport, and you should have a highly qualified pharmacy consultant on your team. Do your part, but also lean on the expertise of your teammates to help make your patients safer and reduce your facility liability.

Class dismissed! If you have questions or need additional tutoring, there is no need to stay after school…you can just reach out to us.

The Consultant Pharmacists at OctariusRx provide guidance on safe medication management, survey readiness and cost savings to ambulatory healthcare facilities/surgery centers, senior care facilities and pharmacies. We also help individual patients optimize their medications to improve their quality of life and save money. Contact us for assistance.