Just Culture Safety Science Framework Can Help Reduce Medication Errors

The use of a just culture safety science framework can be a valuable tool for pharmacists and pharmacy technicians to help reduce medication errors, according to a session at the American Pharmacists Association 2022 Annual Meeting and Exposition. The framework helps to balance safety and accountability in preventing medication error by identifying the root cause and avoiding blaming and shaming the individual.

“When you have a closed system, it’s something that you work all the processes to try to figure out how to keep things as safe as possible, how you can reduce the liability for your organization,” Jennifer Adams, PharmD, EdD, FAPhA, FNAP, associate dean for Academic Affairs and associate professor at the Idaho State University College of Pharmacy, said during the session. “Just culture is one of those frameworks that our health system colleagues use pretty consistently.”

Patient safety is the responsibility of the system, but it is also the responsibility of every individual who plays a part in that system. Regulators hold the individuals accountable to help promote optimal patient safety.

The organization’s role is to contribute to the processes and help to improve them; however, if the organization does not take any accountability and only punishes the individual, then the root cause of the issue may never be identified. Adams added that the framework considers both accountability and safety issues and works to balance justices in the workplace.

The types of justices discussed during the presentation were retributive justice, which provides consequences for rule violations; substantive justice, which establishes the rules and regulations and deems them fair and legitimate; procedural justice, which sets processes for identifying those who violate the rule, offers protection for those who violate those rules, and decides who makes those determinations; and restorative justice, which helps to restore the status and heal relationships and injuries of individuals who are victims of an ethical breach.

Adams expressed hope that restorative justice will become the basis of justice in the pharmacy profession.

However, accountability alone has unintended consequences, she said. Too much accountability can result in less disclosure of errors, whereas a lack of accountability can negatively impact the public’s trust in the pharmacy profession.

Adams said that a culture of shame can lead to increased burnout and decrease the well-being of pharmacy professionals.

To prevent this, she said that the pharmacy organization should investigate all errors. Adams added that identifying the root cause of the error, without punishing the individual for minor errors, is essential for reducing medication errors.

In 2017, Adams said the Idaho State Board of Pharmacy implemented a corrective action plan (CAP). The CAP changed the board’s discipline approach to an informal one that would not go on an individual’s record. If the pharmacy professional does not take action from the CAP, then formal discipline on their record could be implemented.

Then in 2019, the board started to integrate culture of safety principles into the CAP, and in 2020, they continued to integrate the safety sciences framework into CAP.

“Rather than a formal resolution, [the board staff] offers a CAP to the licensee, but it requires them to come to the table,” Nicki Chopski, PharmD, executive officer of the Idaho Board of Pharmacy at the Idaho Division of Occupational and Professional Licenses, said during the presentation. “A near miss should be treated with, essentially, the same seriousness as [a serious incident].”

The CAP is offered to pharmacists and pharmacy technicians by the board to provide an informal resolution for minor routine cases, rather than a formal resolution. This approach provides pharmacy professionals with additional ways to resolve medication errors when formal discipline or punishment is not necessary. Additionally, the CAPs are not recorded on the individual’s permanent record.

In the Idaho Board of Pharmacy, Chopski said that from July 1, 2018, to June 30, 2020, approximately 9.5% of medication complaints were able to be resolved by CAPs. Chopski noted that not all medication complaints are about medication error.

She said that as front-line workers, staff should be promoting safety culture within the pharmacy. They should also propose process improvements if they see fit because they could help to improve the system and bring suggestions to the board of pharmacy.