Medication safety officer role adds value to hospital pharmacy

They serve a variety of roles for hospital

For hospital pharmacies that are considering advocating for a new position dealing with medication safety, the first question might be: What does a medication safety officer do?

Medication safety officers (MSOs) have many different skills, including medication expertise and a good understanding of how the medication use process works, says Deb Saine, RPh, MS, medication safety manager at Winchester Medical Center in Winchester, VA.

"We have to be collaborative and team-oriented because medications aren't used just in the four walls of pharmacy," Saine explains. "We have to keep the big picture in mind and think of all the different disciplines that interface with the medication use process."

Plus MSOs need good leadership and communication skills because they'll have to influence practice changes, she adds.

Here are some of the processes and tasks MSOs can perform:

• Promote culture of safety: Medication safety officers need to promote a culture of safety throughout a hospital organization, from front-line staff to leadership, Saine says.

"This culture acknowledges that humans make errors, so when we design processes around medication use, we build in redundancies, countermeasures, and safeguards to prevent errors from happening," she explains.

"It's very important that the organization encourages reporting errors that have occurred or areas of risk for patient harm," Saine adds.

One way to do this is to look at medication errors with a systems-based approach, meaning that the process for capturing errors is not focused on individuals, but on trends and errors that might result from workflow and system problems.

Also, MSOs help health care organizations learn from past mistakes by initiating process and system changes that will reduce the risk of medication errors.

"The last thing is to make certain there is accountability for health care workers' actions and their job performance related to handling medications," Saine says.

"All of these address the idea of culture or safety," she adds. "As a medication safety officer, you really depend on information from front-line staff that is doing the work because if you don't know what's wrong, then you can't fix it."

• Collect medication error data: Most of the information that will help a medication safety officer identify system and process problems related to medication errors will be collected from error reports.

Hospital staff will report a risk or incident that occurred, and the MSO will collect the data. Or else electronic dispensing equipment or medication orders will collect data about mistakes that were prevented.

"When we use automatic dispensing cabinets, that technology gives us information on how many drugs were obtained by override by the nurse, and we can drill this information down into which drugs, which area, and which reason they were overridden," Saine says. "Then we look for risk factors in the data."

Also Smart Pumps collect information on how many times alerts were issued and what nurses did in response to the alerts.

Whether a health system collects voluntary medication error reports or has technological methods of collecting information, it's important to supplement this information with one-on-one encounters.

"The other ways I get information is through safety rounding, asking staff questions, observing how they practice," Saine says.

Medication safety officers can visit staff and speak with them about their individual medication safety issues and concerns, Saine says.

MSOs also can attend committee meetings, picking up on trends and issues in these venues.

The key is to engage with people in settings where they might be comfortable discussing medication problems they've experienced or witnessed.

A final source of error information is from external resources, such as newsletters, Joint Commission sentinel event alerts, publications, and journals. These sources might identify a trend with a particular product or practice that also is common to the MSO's hospital.

• Assist with special projects: Medication safety officers can be leaders in special projects, including transitions from paper-based or mechanical processes to electronic processes with new technology.

"When we were thinking of transitioning from old IV pumps to Smart Pumps, I led the team that looked at the selection of those pumps," Saine says. "Once we selected that pump, it was my responsibility to coordinate building the drug library, coordinating updates, and providing ongoing monitoring, using the technology performance improvement software."

In another project related to the Joint Commission's patient safety goal for anticoagulation therapy, Saine was the leader of an interdisciplinary team responsible for meeting that goal.

"When that standard was published, hospitals had one year to prepare before they were expected to have everything in place," Saine says. "We had six hospitals involved in the project to meet those requirements for the safety goal."

Through Saine's leadership, the team convinced the hospital to hire a pharmacist who specializes in anticoagulation management.

MSOs also can help hospitals implement new or improved risk reporting systems.

"I helped to drive the need for that because I was looking for improved data on our medication errors and adverse events, and these weren't present in our current system," Saine says. "So we interviewed different companies, selected a system, and it was my responsibility to build the module for medication management, error reporting, and adverse event reporting, and that's system-wide."

Saine also works on paper order sets and computerized provider order entry (CPOE) to make sure all error sets are built clearly and safely and comply with all standards of practice.

"I do that by teaching pharmacist specialists, including a critical care specialist, an anticoagulation specialist, and a pediatric specialist, what they need to look for in terms of errors, safety, and prevention when they review those orders," Saine says. "I provide a checklist for them because the number of order sets built are too much for one person to review."

"My goal is that they will teach this information to the students and residents they round with," Saine says. "Our biggest challenge is influencing performance and how others work and making certain they integrate medication safety in their day-to-day work."