Tip of the Week: Avail Employees of Tools that Can Improve Patient Safety


Health information technology is becoming available an accelerated pace, and it will take time to train individuals on how to effectively employ a new technology and convince them of its merit.

Technology and technological breakthroughs abound. Some individuals use technology primarily to play games and share pictures of pets, while others use it to help solve complex problems that plague entire human populations. Health information technology is becoming available an accelerated pace, yet its uptake by end-users can be a bit slower. It might take more time to train individuals on how to effectively employ a new technology and convince them of its merit than engineers to develop the technology.

Investigators have described the training undertaken by pharmacists employed in a technology-based intervention study, in the International Journal of Pharmacy Practice. The PINCER trial identified patients at risk from harm associated with pharmaceutical indicators such as patients with asthma being prescribed a beta-blocker, patients with peptic ulcer disease being prescribed a nonspecific nonsteroidal anti-inflammatory drug, patients on lithium therapy who require their levels be monitored every 3 months, patients on warfarin to have their international normalized ratios for blood clotting monitored every 12 weeks, and patients on oral contraceptives with a past history of venous or arterial thrombo-embolism.

Six pharmacists received 22 hours of training over 5 sessions. The training involved identification of these markers in patients, effective intervention strategies, and use of software tools to support the implementation of root cause analysis (RCA).

RCA is among the strategies recommended to promote medication safety by the Institute of Healthcare Improvement for advancing patient safety. It employs the use of a series of questions, graphics, and interconnected data to identify system vulnerabilities and implement strong actions that will mitigate or eliminate these vulnerabilities. It takes a systems perspective in the awareness that most quality problems or errors are not the result of an individual’s incompetence or malevolence but more likely attributable to system failures.

The pharmacists in this study who underwent the training reported a high level of satisfaction and greater confidence that they could identify and minimize existing errors, as well as potential errors by utilizing software that coincided with the objectives of the program.

Pharmacy managers must have the know-how and savvy to evaluate the cost-effectiveness of various technologies. Quite often, investment in such technology will reap its return many times over. However, vendor quality varies, and logistically there might be only so much space, capacity, capital, and time to invest in technologies. Any investment in technology must be accompanied by adequate training, buy-in, and a rational purpose that comports with the organization’s mission and scope. Of course, improving patient safety should be within the scope of every pharmacy organization.

Additional information about “Managing Technology that Supports the Medication Use Process and Preventing and Managing Medication Errors: The Pharmacist’s Role”can be foundin Pharmacy Management: Essentials for All Practice Settings, 5e.

Shane P. Desselle, RPh, PhD, FAPhA, professor of social/behavioral pharmacy at Touro University California in Vallejo.


Sadler S, Rodgers S, Howard R, Morris CJ, Avery AJ. Training pharmacists to delivery complex information technology intervention (PINCER) using the principles of educational outreach and root cause analysis. Int J Pharm Pract. 2014;22:47-58.

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