Individual Practice: What s in Your Routine? WRHA Presentation By Susan Balagus

Transcription

1 Individual Practice: What s in Your Routine? WRHA Presentation By Susan Balagus

2 A Day in the Life of a Pharmacy Technician: It s a busy place..all the hustle and bustle! Filling, compounding, checking, answering phones, order entry, helping patients/staff at the counter/window. the list goes on-and-on. We all make mistakes or have caught ourselves before the mistake happens. What do you do to prevent it from happening again?

3 What We Will Discuss Today: What has been done already to help Technicians' prevent errors. What you can do as an individual to prevent errors. How to do a self-assessment. How you and your co-workers can contribute to your Pharmacy as a whole to prevent errors.

4 Preventing Errors - What Has Been Done: There have been many processes put into place to help prevent errors for the Pharmacy Technician. Flagging of high alert drugs. Standardized labeling. Validation of checkers for Tech-Check-Tech including a standardized checking processes. Scanning/hand held devices (ParRx)

5 Implementation of Pyxis dispensing systems in hospital settings. Implementation of CII Safe for narcotic dispensing in hospital settings. TALL-Man lettering. Unit dose packaging. Standards of practice for IV preparation including Aseptic Validation Posted Occurrence Reports for group learning. Regular distribution of ISMP Medication Alerts by the WRHA.

6 Individual Processes to Prevent Errors: To prevent errors on a personal level, we must first perceive ourselves and our actions as part of the overall process to prevent errors. We are responsible for ensuring that the safety, accuracy and quality of products are met before any drug is released. Setting personal standards will assist in a safe process. What can you do to maintain competency?

7 Have a set routine for each task. This is an important part of taking responsibility for your work. Know your limits within your environment and adjust accordingly. - Workload. - Time restraints. - Activities going on around you. (talking, noise level, interruptions) - Uncertainty about task being performed. Have an open and honest dialog with management/staff about mistakes. This includes near misses and IV contaminations.

8 Self-Assessment Using a self-assessment tool on a regular basis when an error/near miss happens will give you the ability to develop personal improvement strategies. This will enhance your individual practice techniques and routines. It promotes a safe work environment within your Pharmacy. It also incorporates learning into your everyday practice.

9 Steps for Self-Assessment: You can create your own assessment tool to meet your individual needs. The following is a basic guideline: Ask yourself.. 1.) Where in the process of my work did I miss a step? 2.) Do I need to add a step to my routine? 3.) Do I need to change the order of my routine?

10 4.) Has there been a change in the procedure that I m not aware of? (clearer communication) 5.) Do I need to review the current procedure? 6.) Is there something in my environment that contributed to the error/near miss? 7.) Did I get interrupted during the process?

11 8.) Was I rushing? Why was I rushing? 9.) Did this happen because of a high workload? 10.) Do I need to organize my workflow better? All these questions will help you to practice safer and prevent errors on a personal level.

12 Contributing to a Safe Pharmacy Department: Have a Culture of Safety established: This is a key component to promoting a safer environment. What is a Culture of Safety? It is defined safety attitudes and practices within the organization that help employees work towards a common goal.. Safety and quality care.

13 Taking part in a Culture of Safety means that you care about your co-workers as well as patients. In a culture of safety, we collectively work together to follow procedures set forth by our organization/region which can prevent errors. It also encourages employees to take action and come forward when needed to make things safer.

14 Incorporate the no blame approach within your workplace. This will encourage individuals to come forward in an effort to maintain competence. Have good reactive and proactive responses to errors within your environment. How you act towards people that have made an error can have negative or positive results. This is directly related to the no blame approach.

15 Understand the 3 main factors that contribute to errors so you can support each other in the workplace. 1.) Human Factor (human error) which can be caused by: - Lack of knowledge - High personal and employer expectations - Attention focus - Goals/workload (juggling more than one goal or task at a time) - General health (fatigue, stress, illness, etc)

16 2.) Workplace Environment Factor - Layout of work area - Equipment design (ease of use) - Environment (noise level, lighting, temperature, air quality, etc) 3.) Management Factor - Organization of systems. - Policies and procedures are clear, kept up-to-date and accessible. - Management involvement in decision making. - Communication/feedback from staff.

17 Understand the root causes of errors in the Pharmacy: - Repetitive tasks - Emphasis on volume over service quality. - Look-alike/sound-alike products/labels. - Ineffective communication.

18 When personal practices and routines are set in place, error prevention becomes a part of you. When we all work together in a Culture of Safety, error prevention becomes a part of everyone. Final note: Remember: We all come to work with the intention of helping others. We do not intend on making mistakes. Potential errors exist in every task we perform. Do you part to prevent them by assessing yourself regularly.

19 Questions?

20 References: Developing a Culture of Safety: Taking Safety Personally Medical News Today article php Pharmacy Technician Competency Assessment The University of North Carolina ISMP Canada: Medication Safety Self-Assessment (Canadian version II): Recommendations for Reducing Medication Errors: Individual Actions to Reduce Patient Risk article _4: Professional Competencies for Canadian Pharmacy Technicians at Entry to Practice: NAPRA Behind Human Error Human Factors Research to Improve Patient Safety by David Woods Medication Error Reduction: The Pharmacy Technician s Role by E. Dunn and J. Wolfe (jpt 1998;14:70-7) Identifying Factors that Cause Pharmacy Errors: Gerard Gianutsos PhD University of Connecticut School of Pharmacy