Expert Suggests Shifting “Blame and Shame” Culture to Improve Safe Medication Therapy Management for Oncology Patients


Improving the process of safe medication therapy management requires comfort, trust, and fostering a culture for safe communication.

Grace A. Martin, PharmD, BCOP, Pharmacy Clinical Coordinator, Cancer Care at the University of Kansas Health System, Overland Park, Kansas, discusses how pharmacists can use a multidisciplinary approach to increase the safe use of cancer therapy with Pharmacy Times at the Hematology/Oncology Pharmacy Association (HOPA) Annual Conference 2023.

PT Staff: What does a multidisciplinary approach look like for facilitating safe medication therapy?

Grace A. Martin, PharmD, BCOP: I think a multidisciplinary approach is really important to make sure we have the right people in the room to make decisions about how we administer, prescribe and give our patients medication therapy and how we monitor them. We have physicians, advanced practice providers, pharmacists, and nurses, the treatment nurses, even our schedulers are really important to make sure that patients have the appropriate follow up to receive appropriate monitoring and their timing of their medication therapy.

PT Staff: What are barriers to medication safety?

Grace A. Martin, PharmD, BCOP: Yeah, I think some of the barriers to medication safety are fear of reporting. So, we often are in a “blame and shame” culture where people are pointing fingers if someone makes a mistake or if something happens, instead of looking at the process as a whole. It's pretty easy to place blame on another person or to feel a shame to come forward if an error does occur. And so I think that's one of the biggest barriers; just not having a culture of safety.

And that's something we've been working really hard to change so that people feel comfortable reporting even near misses, if there's a possibility that something could go wrong. Those are the things we want to know about. How could we potentially prevent harm for future patients? And so that's one of the biggest things. Other things would be if people don't know how to report events, or if there's not appropriate follow-up, especially with management. People need to be able to trust their leadership team, that they are going to handle these events appropriately so they can still maintain trust within the teams they're working on. If someone reports an event, they need to feel comfortable that they're not going to have any backlash from the people they're working with. So if we create a process where we're always looking at, what can we do better as a whole, and there are multiple ways that this potentially went wrong. That's what we're looking at is how can we improve the process and not point fingers at the people. And that's how we can improve reporting and make sure that we know about Safe Medication Therapy Management.

PT Staff: So you discussed blame as a main barrier to safe medication therapy management- who tends to pass this blame?

Grace A. Martin, PharmD, BCOP: I think that, you know, it can be a lot of different ways in the oncology, pharmacy space, which is where I work, I work in an outpatient area. And so if something goes wrong, it's just kind of looking at around at, well, this person could have been involved or that person. But there are really so many different ways that things could have gone wrong, gone wrong. It's not always coming from the patient, or it could be from a colleague, but we've worked really hard at our institution. So that doesn't happen. So those are things that we are definitely working toward, and are making changes in the way that we practice so that people are comfortable and know that they're not going to be in trouble if if a human error occurs.

PT Staff: Can you discuss the impact of the Oncology Medication Safety Committee on safe medication management?

Grace A. Martin, PharmD, BCOP: So we have a multidisciplinary oncology committee that reviews safety events, or near misses, or even just potential errors, where things could go wrong with medication therapy. And so we come together as a group and we review these events, and are trying to come up with ways in the process that we can improve things are there, it fixes that we could submit to make sure that we improve our order set and make it really clear about what monitoring needs to happen. Do we need to add additional labs? Do we need to change the way that something looks in our electronic health record so that it's more clear? Even something as simple as showing height in inches and feet, or inches instead of centimeters, can make a huge difference when we're talking about height and needing height for body surface area (BSA) dosing for chemotherapy. So, [it’s] just little things like that we find along the way, and a process that can really make a big difference to administer medications safely.

PT Staff: How can pharmacy practice overall adopt a multidisciplinary approach?

Grace A. Martin, PharmD, BCOP: I think in order for this to spread across multiple institutions, it's really important that we're willing to share with each other areas where we are improving. So we go to conferences, we go places, we want to share the great things we're doing. We aren't always as willing to share the things that maybe aren't going as well. And I think that if we're willing to be vulnerable with each other across institutions, and share the lessons that we've learned, that just makes us more open as a profession, to talk about the hard things, and what we can do to improve together and how we can learn from each other and the mistakes that we make along the way. So that's something that I think is really important too. As we're creating these multidisciplinary committees, we have to encourage creating a safe culture of sharing and collaborating. And I think that it just it can start with pharmacists and then spread from there.

PT Staff: What are your thoughts on the use of legal action to mandate safety measures?

Grace A. Martin, PharmD, BCOP: I don't think additional legal measures are necessary to improve this process because it needs to come the decisions about how to improve the process need to come from the people are on the frontlines. That's how change is made. If decisions are being made from leadership or even at a legal, people are going to be more afraid to come forward and share the workarounds that they've created. No one goes to work thinking, I'm going to harm a patient today, or I'm going to make a mistake. That's never our intent. We always are there because we care about the patients, and we want to help our patients with cancer do better. And so it's really important that we start with the people around the frontlines and get the right people in the room to make decisions. And I think the right people in the room are the ones who are taking care of patients. And so they need to say, here are the places in the process that are hard, and we need to make it easy to do the right thing. And how are people just getting through their day and creating work around so they can take care of the patients the best they can? What can we do to simplify that process? How can we make it easy to make the right decision and do the best thing for the patient, not just the thing that works so that the patient is taken care of. But if there are extra steps in a process where potential harm could occur, how can we simplify that? And I don't think that comes from legal measures. I think that comes from the people on the frontlines.

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