Supervision Can Be a Weak Link in Error Prevention

JANUARY 01, 2007
Michael J. Gaunt, PharmD

To improve patient safety, ISMP emphasizes that a systems-based approach must be used to analyze mishaps in the medication use system. Some of the more important system-based interventions to help prevent errors include improving the design and workflow of practice sites, using technology and robotics, adding forcing functions to procedures and equipment, and improving product labels. Despite these interventions, research shows that unsafe practices continue to exist.

Our attitudes toward work and the management styles that surround us may weaken an organization's error prevention efforts. Many work environments are punitive, leading practitioners to feel that they cannot make a mistake, and, if they do, it will be held against them. Paradoxically, these concerns can actually increase anxiety on the job and increase the chances of error. This has been observed among physicians, nurses, and pharmacists in both hospital environments, as well as in community pharmacies.1

A common denominator in overcoming the "I can't make a mistake" philosophy is building better team relationships and effective supervision. Supervision is not only about providing feedback or overseeing work that is in process or completed. Real supervision includes an examination of the interpersonal processes by which such practices are carried out. Research shows that pharmacists who were most satisfied with their jobs and who were involved in fewer errors had supervisors who fostered appropriate autonomy and were perceived as democratic, facilitative, and helpful in setting goals. The supervisors were perceived as effective because they demonstrated better leadership and interpersonal skills and encouraged excellence as well as appropriate independence on the job.

On the other hand, professionals who rated their supervisors lower on leadership and interpersonal skills or who perceived them as overly autocratic and punitive, made more mistakes and intercepted fewer errors. In the absence of training and knowledge, people with supervisory responsibilities usually default to management styles that are more controlling rather than interactive. A focus on negative outcomes and the use of autocratic supervisory practices creates some of the anxiety, stress, and mental distractions associated with error and job dissatisfaction. See the Table2 for a list of characteristics (identified by pharmacists) of effective supervisors.

Although people are not necessarily born with great interpersonal and leadership skills, they can learn to supervise appropriately and interact more effectively with their staff. Unfortunately, such training is not pervasive in health care, and inexperience in how to work with and supervise others often leads to problems. To promote effective supervision and error prevention at your site, supervisors should be provided with leadership training that focuses on managing in a positive and participatory manner. In addition, all employees should be taught how to work with supervisors through training related to communication skills, conflict management, and team building.

Dr. Gaunt is a medication safety analyst and the editor of ISMP Medication Safety Alert! Community/Ambulatory Care Edition.

Subscribe to Newsletter Pharmacy Times and the Institute for Safe Medication Practices (ISMP) would like to make community pharmacy practitioners aware of a publication that is available. The ISMP Medication Safety Alert! Community/ Ambulatory Care Edition is a monthly compilation of medication-related incidents, error-prevention recommendations, news, and editorial content designed to inform and alert community pharmacy practitioners to potentially hazardous situations that may affect patient safety. Individual subscription prices are $45 per year for 12 monthly issues. Discounts are available for organizations with multiple pharmacy sites. This newsletter is delivered electronically. For more information, contact ISMP at 215-947-7797, or send an e-mail message to


1. Edmundson AC. Learning about mistakes is easier said than done. J Applied Behav Sci. 1996;32:5-28.

2. Grasha A. Psychosocial factors, workload, and risk of medication errors. US Pharm. 2002;27(4):HS32-HS52. Available at:

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