Medication Safety: Leadership Establishes Culture

November / December 2008
Medication Safety

Leadership Establishes Culture

I, like many of you, read in July about another heparin-IV versus heparin-flush incident. As reported by, as many as 17 infants in Corpus Christi, Texas, received the all-too-common 1000x overdose believed in this case to have been caused by a mixing error. As of this writing, two of the children have died, though causes of death were still uncertain. Several industry leaders said that barcoding is an obvious solution, but if the error occurred when the drug was being prepared or mixed in the pharmacy department, many found it difficult to understand how a few black lines in a barcode would have made a difference. Even with technology, a pharmacist or a nurse can still prepare an IV in the wrong way or make an error in calculating just how many milliliters of stock heparin solution should be used. That is why a number of articles about the use of stock medications have been written and several robotic IV-dose compounding products have recently been introduced to the marketplace.

So, what do we do now? How many times will there be similar stories reported before someone jumps in (or up and down for that matter!) and says “this is how we will fix the problem!”

Consider This
A cardiologist group in which I practiced identified several special patient-types for whom we instituted a “check twice” treatment policy. This was one of our attempts to talk and practice a culture of safety. These patient-types included those on amiodarone and warfarin treatment regimens, diabetics, or those with acute infections, among others. Each of these patients required a pharmacist consultation and periodic between-visit follow-up to assure proper medication use, to check on side effects, to answer questions, and to minimize the risk of poor treatment outcomes once they left our office.

This follow-up procedure didn’t take much time during the course of the day. A few hours during the week were sufficient to contact these high-risk patients. However, it did require a commitment of technology and time that otherwise could have been spent in other ways. Yes, this policy did indeed add more cost to the practice’s budget, but most everyone felt it improved our treatment outcomes and patient satisfaction. Besides, most of the patients appreciated it and felt the additional contact contributed to their satisfaction with the practice.

With medications, and particularly with medications for children, practicing a culture of safety is essential. But like most pharmacy practices in non-children’s hospitals, medications for children often fall into the category of ordinary work. Since children don’t react, metabolize, and respond the same as adult patients, treating the child at healthcare organizations accustomed to treating adults requires special care — a special culture of safety — to be practiced. It’s too easy to mishandle a dose or to hurry and finish the IV because the “nurses on 3 east are calling.” There isn’t any excuse for not being extra careful, such as instituting a “check twice” treatment policy, or consulting a children’s treatment expert when questions arise when treating a child, or establishing a “child specialist” program in the pharmacy specifically for the neo-natal ICU.

The Business Culture of Healthcare
In this era of staff and resource shortages, reduced focus, and increased distractions, the push to do more with less has become the normal mode of operations. Managers are more cost conscious, and healthcare executives have become budget experts with bonuses often paid when costs come in under expectations. Yes, even the non-profits make money! It would be interesting to determine how many medication errors either in the pharmacy or in a patient care area occur as a direct result of staff burnout, caregivers trying to do too much in too little time, staffing shortages, or some other cultural effect. Culture impacts safety in a profound way, as many healthcare organizations operate as “lean and mean” businesses placing additional stress on all direct patient caregivers as if they were retail clerks. Frankly, do we need to be reminded why our healthcare institutions exist in the first place?

Do our institutions exist to win advertising awards? Do they exist as places to practice investing skills or to develop new software? Are healthcare institutions places to win the next architectural award? Or do they exist to pay CEOs multimillion dollar salaries for new merger deals? While the vast majority of us are committed to safety, sadly, there are some who work in healthcare because “it’s a job.” Would I rather have new marble floors in the lobby or several more nurses staffing a 40-bed unit? Would I rather hear a commercial on a major radio station for the new cardiac service or have an extra clinical pharmacist to manage pharmacokinetic studies? Would I rather hear my CEO received a multimillion dollar retirement package or have new technology for minimizing medication errors? Or do I believe that safety, shortages, stress, and awards coexist in harmony?

Culture Practiced Through Patient Care
In today’s healthcare industry, every organization will say it practices a culture of safety. Still, how many times have you heard a CEO tell the Board their hospital is safe while clinicians are requesting additional staff to accommodate increased workloads and the CFO is saying, “We must hold the line on FTEs”?

Executive management provides leadership to establish the culture of the organization. Staff members hear what management says, listen to others in the community, see what is reported on the airways and in the papers, and intently note through experience what is actually done. Let’s not forget for a minute how aware every staff member is about the “culture” of the organization. Because of what is seen and heard, there often is a gap between management talking (i.e., providing leadership) and staff practicing the culture. Will your staff members say your organization practices a culture of safety? If the clinical staff is stressed, how will the culture of safety be impacted?

A culture of safety demands special policies for special patients. And management must provide the leadership to commit the resources (technology and people) so that special policies for special patients become part of the culture. There isn’t any excuse in spite of the marble floors, the radio commercials, or the investment and retirement packages. To work in a culture of safety is among the primary reasons why most of us have chosen careers in healthcare.

Larry Pawola is associate professor and associate dean on the faculty in the College of Applied Health Sciences at the University of Illinois at Chicago. He also is president of his own healthcare information technology and clinical services consulting firm, Lincolnshire Consulting Associates LLC. As a respected industry consultant for more than 25 years, Pawola has worked with a variety of ambulatory clinics, community hospitals, and academic medical centers. His work has focused on assessing clinical systems needs, operational improvements, strategic planning, and education. He has also consulted with healthcare companies for the strategic positioning of their technology products. Pawola is a member of the Editorial Advisory Board for Patient Safety and Quality Healthcare. He may be contacted at