NQF safe practice: More pharmacist involvement

In issuing its 2009 safe practices, the National Quality Forum (NFQ) recommends more pharmacist involvement. Safe Practice 18: Pharmacist Leadership Structures and Systems reads: Pharmacy leaders should have an active role on the administrative leadership team that reflects their authority and accountability for medication management systems performance across the organization.

"The whole issue of medication management is high profile in patient safety, and the improved integration of pharmacists into the whole spectrum of medication management is important, and so as part of our safe practices' ongoing maintenance program, this is one that we have chosen to profile and make important," says Peter Angood, MD, NQF senior advisor on patient safety.

"We are all well aware of how critical medication management is and how common the adverse events are related to medication management, so several organizations have some type of initiative going," he says, mentioning The Joint Commission's chapter on medication management and the work being done by the Institute for Healthcare Improvement, the Institute for Safe Medication Practices, and U.S. Pharmacopeia.

He says the NQF's work in integrating pharmacists and leadership is "fairly unique."

"Within the actual content of the safe practice, we not only provide the specifications of the practice, but we also provide a variety of example implementation approaches, opportunities for patient and family involvement, how should organizations put in the different structural components, the processes, and what are the expected outcomes for implementing these types of measures."

Some suggestions in safe practice 18 include:

  • pharmacists should work within an interdisciplinary team to ensure safe, effective medication for patients across the continuum of care from setting to setting;
  • establishing pharmacy leadership structures and systems to ensure awareness of medication safety gaps, direct accountability from leadership for gaps, and a budget available for performance improvement;
  • supporting a culture that furthers safe medication use, providing feedback to staff, and implementing interventions to ensure safe medication use;
  • identifying and mitigating safety risks and hazards to reduce patient harm;
  • establishing a medication safety committee to review medical errors, adverse drug events, and near misses;
  • performing medication safety walk-arounds;
  • establishing a role in readiness planning for implementing a computerized physician order entry system;
  • engaging in public health initiatives.