/publications/issue/2004/2004-05/2004-05-7875

Keep Your Eyes on the Prize: Patient Safety

Author: James C. McAllister III, MS, FASHP, Editor, Health-Systems Pharmacy Section

I remember the theme of American Society of Health-System Pharmacists President Bruce Scott's presidential address several years ago, "Keep Your Eyes on the Prize." He was not focusing on patient safety necessarily, but I remembered his message as I contemplated writing this editorial. No one could argue the importance of patient safety and the responsibility all of us who practice in the health care system have to eliminate medical errors.

I remember wondering whether the patient safety issue would be another "buzz phrase" that would run its course and disappear like "total quality management." The profound and compelling studies by Bates, Bootman, and others were certainly galvanizing works that enjoyed well-deserved notoriety. These studies were followed by the Institute of Medicine's To Err Is Human, and the prestige of the institute, the thoroughness of the publication, and the attention it enjoyed in the media made patient safety a national priority, guaranteeing it enduring status.

Hospitals (and their providers) have been besieged by regulatory organizations, consultants, and professional associations that have promulgated well-intentioned standards, recommendations, and guidelines, which they believe will improve patient safety?and many of their "suggestions" will reduce medical errors. At the University of North Carolina Hospitals, we have been struggling to meet Joint Commission on Accreditation of Healthcare Organizations expectation standards by eliminating illegible handwriting, developing and enforcing lists of prohibited abbreviations, and launching a verbal-order policy that discourages verbal orders in general and prescribes a specific procedure that must be followed to ensure effective communications.

Some may argue that challenging these initiatives as a system priority is unconscionable because we all know the potential for these problems to cause medication errors. As a colleague at another institution lamented, however, "Is having my staff call prescribers hundreds of times a week to rewrite "once per day" instead of "qd" an optimal use of their time? Keep your eyes on the prize!

Wouldn't patients and institutions be better served by working on hig-hrisk, high-volume systems, processes, and drugs prescribed that have been identified as opportunities for significant improvement? The diversity among hospitals, their resources, infrastructure, mission, and practices render a cookie-cutter approach to improve patient safety less than optimal, except for the most pervasive risky practices (eg, concentrated electrolyte availability). It seems to me that each institution and its providers should be focused on systems and practices in their specific organizations.

Unique opportunities to improve patient safety in pediatrics, cancer care, and intravenous therapy abound. Are we focusing enough attention there? Should we consider compliance, patients understanding their drug therapy, and achieving intended outcomes as patient safety issues? Presuming that treatment failures, readmissions, and disease progression are not patient safety issues, what priority should they be assigned with limited resources? Keep your eyes on the prize!

My point is that we must maintain patient safety as a top priority and endeavor to eliminate errors when possible. Maintaining balance in our mission?helping people make the best use of their medicines?must not be forsaken in the process. Keep your eyes on the prize!