7/28/2019 MCrowe Michigan Pharmacist Patient Safety July 2013

1/2MichiganPharmacists.org 16 2013 July/Aug./Sept. | Vol. 51, Issue 3

PATIENT SAFETY

Strategies of the MPA Patient

Safety Task ForceDuring the rst meeting o the Task Force,

members identied a multitude o strategiesor improving patient saety. The group agreedthat each o these strategies could be orga-nized into one o ve broad categories: patienteducation and communication, health care

proessional education, access and exchangeo health inormation, just culture environmentand pharmacy workfow. Moving orward,time was spent rening what actions could betaken, and what recommendations would bemade within each o these categories.

Patient Education and CommunicationInitial ideas o the Task Force or patient

education and communication includedspreading awareness through letters to theeditor and social media, enhancing pharma-cist education given to patients, and physicalresources that could be distributed to patients

at their local pharmacy. Overall, the groupsocus was on a patient saety resource centerand the Thats My Pharmacist campaign.

Patient Saety Resource Center. Aweb-based patient saety resource centerwas identied as a top priority duringMPAs 2012 strategic planning retreat.This project was charged to the TaskForce and, in response, the group asa whole brainstormed several compo-nents to be included in the resource

center. The group recommended thatthe resource center have a public-acingpage, which links out to patient-specicand health care proessional-specicpages. Because this resource center willbe based online, and MPA is currently inthe process o redesigning its Web site,seven Task Force members volunteeredto serve on a standing workgroup toconsult with MPA moving orward.

Expanded Thats My PharmacistCampaign. It was decided that utiliz-ing the Thats My Pharmacist campaign

as a means o increasing patient saetyawareness and to provide resources topatients would be ideal, as the cam-paigns brand recognition is alreadyestablished. Thereore, three Task Forcemembers volunteered to work with MPsta on expanding the Thats My Phar-macist campaign to encompass patien

saety eorts. As part o this eort, pa-tient medication cards were developedwhich included questions the patientshould ask his/her pharmacist, such aswhat a medication is used to treat andwhat to expect. Several Michigan pharmacies made this postcard available topatients in the all o 2012.

Health Care Professional EducationThe Task Force spent a great amount o

time discussing strategies related to healthproessional education. In addition to thepreviously described resource center, three

other saety-enhancing strategies were idened specically or health care proessiona

Patient Saety Certifcate Program. Aproject assigned to and discussed by tTask Force was the development o a ptient saety certicate program. The TasForce agreed that a certicate programgeared toward pharmacists and technicians, should be promoted to the MPAmembership. A subgroup was ormed research what other programs alreadyexist and the Task Force recommendedthat a survey be conducted to determi

the memberships level o interest.

Mandatory Saety Continuing EducatioThe Task Force made a recommendationthat one hour o continuing education (Con the topic o patient saety, be requiredo every pharmacist during each licensingcycle. This is not a new concept, as vestates have already mandated patient saeCE as a requirement or licensure renewa

Annual Convention Saety Track. TheTask Force recommended that MPAprovide a saety track at the 2013 Annu

Convention & Exposition. As a result,several programs were oered during thConvention, including continuous quaimprovement, the role o the technicianhuman actors and medication errors,each as they relate to patient saety.

Access and Exchange of Health InformatiThe Task Force held many discussions

ocusing on access to health inormation.The ocus was on what pieces o inormatiwould be helpul to a pharmacist in practiincluding data such as diagnosis, othermedications and laboratory values.

Developing Strategies toImprove Patient Safety

By MICHAEL CROWE

Pharm.D.

Patient saety was identied as a key strategic issue o MichiganPharmacists Association (MPA) in 2011. As a result, the Patient SaetyTask Force was ormed and charged with developing strategies topromote patient saety. Meetings o the Task Force began in October2011 and continued through September 2012. Subgroups were ormedto work on specic strategies, some o which are still active today.

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7/28/2019 MCrowe Michigan Pharmacist Patient Safety July 2013

2/2MichiganPharmacists.org 17 2013 July/Aug./Sept. | Vol. 51, Issue 3

PATIENT SAFET

HEDIS Measures Improvement Pilot.The timeliest opportunity related to thistopic was involvement in a pilot projectwith HealthPlus o Michigan. The goalo this pilot was to improve HealthcareEectiveness Data and Inormation Set(HEDIS) measures by providing addition-al patient-specic health inormation topharmacists as well as compensation orsuccessul interventions. The Task Forcehas provided our members to serve onHealthPlus planning Committee or thispilot. During the rst meeting, diabetes

was identied as an initial area o ocus,and adjudication sotware sot edits wereselected as the mode o sharing patient-specic health inormation. In the case odiabetes, pharmacists will receive a sotedit message or diabetic members need-ing their A1C or LDL drawn. The pharma-cist will then provide education regardingthe needed services to these members.As o October 2012, HealthPlus haspartnered with a select group o indepen-dent pharmacies to perorm interventionsin patients with diabetes. As the successo the initial interventions is evaluated,

the pilot is expected to expand to otherpharmacies and other disease states. Thisevaluation process was tentatively set totake place by the end o the rst quartero 2013, during which the Task Forceplanning Committee members wouldcontinue to provide assistance.

Just Culture Environment

To rene strategies alling under just (non-punitive) culture, Task Force members wereelectronically surveyed between meetings toprioritize culture and saety ideas identiedduring the rst Task Force meeting. Ater

prioritization and a ollow-up meeting, theTask Force has made the ollowing recom-mendations to the MPA Executive Board.

Modifcation o Public Health Codeto be Less Punitive. It was the consen-sus o the Task Force to recommend tothe Executive Board that the Associa-tion support legislation to create a lesspunitive environment by establishinga mechanism or action taken againstpharmacists licenses, a process simi-lar to a drivers license, and be gradedbased on the impact the causative act

has on the patient.

Promotion o the Institute or PatientMedication Saety and PharmacistPeer Review. The Task Force concludedthat MPA should continue to assistin keeping the Institute visible to themembers. This could be accomplishedby sending a ax blast about the Institute,highlighting the benet to the pharmacistand emphasizing the condentiality othe inormation. By doing so, MPA wouldbe promoting the value o sel-reporting.

Continued Support o Licensure andCertifcation o Pharmacy Techni-cians. The Task Force recommends thatMPA continue to support the legislationthat will require licensing and certica-tion o pharmacy technicians. The TaskForce urther recommends that MPA en-courage pharmacists and pharmacies tohave their technicians become certied,even though it is currently not mandated.

Pharmacy WorkfowThe issue o pharmacy workfow and its

relation to patient saety was one o the mostdicult to address. Not only is workfow sub-

ject to the physical layout o each pharmacy,it is also subject to the operating proceduresalready established by each pharmacy.

Workplace Stress Management Educa-tion. One commonality identied innearly all practice environments wasstress due to the many requirements opharmacists such as prescription ll ratemetrics, immunizations, consultationsand rell calls. The Task Force, thereore,recommends that MPA provide a CE

program (possibly a workshop) on bestpractices to handle pressure and stress inthe workplace to enhance patient saety.Tools that help decrease workplace rus-trations should also be promoted (e.g.,Simpliy My Meds rom the NationalCommunity Pharmacists Association).

Pediatric Oral Compounds Standard-ization. A niche area within the categoryo pharmacy workfow, in which theTask Force will continue to contribute,is standardized ormulation o pediatriccompounded oral liquid medications. Jim

Stevenson and the University o Michigare currently undertaking a Food andDrug Administration grant-unded re-search and process improvement projecIt is a statewide collaboration to standaize compounded oral liquids. The ourphases o the project are to survey pharmacies, analyze the results and developstandards, disseminate the standards anmeasure their impact.

The Task Force rst provided assistanceby reviewing the survey and providing

eedback, and providing suggestions othe projects Committee members.In late September, the project Commit-tee held a very successul meeting at thMPA headquarters. During this meet-ing, the project outline was presented,the results o the baseline survey werediscussed and worksheets on 160 di-erent target medications were handedout. Many o these drugs were beingcompounded in upward o 10 dierentormulations. Thereore, the group thenestablished principles or what conditioshould exist to dene a standard con-

centration and conducted a preliminaryreview o the 160 medications, selectinthe best possible ormulations. Exampleo these principles included having apublished ormulation, having a stabilito at least 30 days, being relatively easyto compound, and having a ormulatiothat uses readily-accessible component

Project Committee leaders are currentlydoing background work on the potentiastandard concentrations, determiningwhether they meet the principles thatwere established in the meeting. Once

this is completed, a second meeting wibe held to try to nalize a proposed liststandards, which will then be circulateor comment to a more broad popula-tion o pharmacists, physicians and othstakeholders. This is anticipated to becompleted the rst quarter o 2013. Atestablishing the standard concentra-tions, the project will then move into thdissemination phase: working with MPto communicate these standards andencouraging all pharmacies in the stateto adopt them in the interest o improvpatient saety.

Members of the MPA Patient Safety Task ForceMike Crowe, chairman

Larry Wagenknecht,

MPA sta liaison

Tim Arnold

Rose Baran

Denise Bluhm-Heise

Mary Burkhardt

Eleni Butzin

Paul Chludzinski

Ray Dorhout

Angela Faszczewski

Lynn Glasser

Joe Leonard

Dan Lobb

Mike Major

Doug Miller

Paul Miller

Carol Raznik

Sarah Oster

Greg Pratt

Pat Quinn

Brenda Ruhlman

Tim Sti

Kevin Szyskowski

Bill Walker