Pharmacy school curricula are prioritizing patient safety to prepare future pharmacists for their vital role in keeping patients safe.

By Jane E. Rooney

It’s something we often take for granted, because we assume health professionals are being vigilant and have been trained to consider crucial questions such as: Has the patient received the correct medication? Is the proper dose indicated on the prescription label? Will the medication have any harmful interactions with other prescriptions being taken? Patient safety is paramount, but most people probably don’t give it much consideration when the healthcare system is operating as it should.

The reality, however, according to World Health Organization (WHO) statistics, is that four out of every 10 patients are harmed in primary and ambulatory care settings. The most detrimental errors are related to diagnosis, prescription and the use of medicines.

WHO defines patient safety as the absence of preventable harm to a patient during the process of healthcare and reduction of risk of unnecessary harm associated with healthcare to an acceptable minimum. Guidance from the organization indicates that “clear policies, organizational leadership capacity, data to drive safety improvements, skilled healthcare professionals and effective involvement of patients in their care, are all needed to ensure sustainable and significant improvements in the safety of healthcare.”

Pharmacists clearly play a crucial role in keeping patients safe. The Alliance for Patient Medication Safety (APMS) is a federally listed Patient Safety Organization (PSO) that works with independent and regional chain pharmacists on patient safety initiatives. Its mission is to help community pharmacies implement and maintain continuous quality improvement programs to improve patient care. Their programs help pharmacies comply with health insurance and state and federal quality assurance requirements.

“We emphasize that every pharmacy put in place a learning environment instead of a punitive environment in order to build a safe, just culture,” explained Tara Modisett, executive director, Alliance for Patient Medication Safety. “When a strong safety culture exists where the staff feels empowered to say ‘hey, this is a workaround or a process that isn’t the safest practice,’ and their input is valued and respected, good conversations can result. Most community pharmacies already deliver the safest care they know how to but PSOs provide resources and help to take it to a higher level.”

Last year, the Patient Safety Movement Foundation developed a core curriculum—available for free to all professional healthcare schools—to teach patient safety from the first professional year through residency. Chapman University School of Pharmacy (CUSP) has committed to this curriculum, which will begin during the first year of school with the goal of creating entry-level practitioners with a broad knowledge base and skills that can be used to improve patient safety. “We know Adverse Drug Effects are the fourth leading cause of death in America. We also know pharmacists are in communities within five miles of every citizen,” said Dean Ronald P. Jordan. “CUSP faculty are fully committed to ensuring our students become expert sources of safety information. By adopting Leadership in Patient Safety Education as a pillar of our school’s strategic plan, we seek to lead pharmacy schools to teach students and other health professionals to think safety first.”

Diagram of Patient Oriented Safety Care
Figure 1: Creating a culture of safety challenges the idea of a hierarchy in patient care and it is instead replaced with an integrative approach including the patients, family members, and healthcare professionals while combining technology, systems, and communication methods in order to achieve the most patient-centered care possible.

Both the CAPE Outcomes and the 2016 Accreditation Standards outline the topics student pharmacists must learn to optimize the safety and efficacy of medication use systems. “All pharmacy schools emphasize patient safety and talk about it in a broad sense,” said Dr. Mary Douglass Smith, Presbyterian College School of Pharmacy’s interim executive director of experiential education. “I think being able to share errors and dig into more specifics will help students be more prepared for what the profession will be like. There will be errors but this is how we mitigate them and solve them. These are practical ways to put safety at the forefront of practice.”

Steps Toward Better Communication

Dr. Catherine Hatfield, director of interprofessional education and clinical associate professor, University of Houston College of Pharmacy, said the main thing pharmacists can do to ensure patient safety is learn to speak up. “When you see something that doesn’t sit right with you, you have to be able to speak up and be a team member if the dose isn’t right or the drug isn’t right,” she noted. “If you are too afraid to speak up about an error, you are a part of the problem.” Hatfield attained the Institute for Healthcare Improvement (IHI) Patient Safety Certification several years ago and decided the information she learned was important enough to pass along to student pharmacists. What began as an elective became a required course in Houston’s curriculum in 2019.

TeamSTEPPS 2.0 diagram

Another key part of the curriculum is TeamSTEPPS, a standardized framework of communication to improve patient safety that originated with the federal Agency for Healthcare Research and Quality. It is an evidence-based set of teamwork tools, aimed at optimizing patient outcomes by improving communication and teamwork skills among healthcare professionals. “I’ve been teaching it in our curriculum since 2014. It is something that should be taught to all health professions,” she said. “It’s about learning how to communicate and speak up to reduce communication errors, which is one of the biggest fixable patient safety issues in healthcare today.” She believes we need to get away from training healthcare professionals in silos and that there should be a movement to get TeamSTEPPS into every pharmacy school, which will ultimately lead to improved patient safety.

“There are tools within TeamSTEPPS that train everyone how to communicate,” she continued. “One is called the SBAR (situation, background, assessment, recommendation) model. If a pharmacist can learn to speak that way to a doctor or nurse and that other health professional has been trained in SBAR, they can communicate effectively. CUS (concerned, uncomfortable, safety issue) is another one. If you get frustrated or upset, you need to figure out a way to communicate with that individual and enter into a dialogue so you can come to an agreement to figure out what is best for the patient. You need to advocate for the patient. When you’re upset and feeling like you’re not being heard, this allows you to express why you’re concerned. The safety issue should stop everything and everyone should come to an agreement and decide if things are proceeding the way they should be.”

Another main focus in the curriculum is learning to recognize errors. “A lot of what patient safety involves is how do we fix system errors so they don’t happen again,” Hatfield said. “We’ve got electronic records so you don’t have transcription errors, but what can you do to prevent the onset of errors? A lot of that is communication. The IHI modules and the patient safety IPE force students to practice speaking up and learn the roles within medicine, nursing and pharmacy and how they work together to improve things for patients.”

A lot of what patient safety involves is how do we fix system errors so they don’t happen again…what can you do to prevent the onset of errors? A lot of that is communication.

Dr. Catherine Hatfield

The second year IPE includes a progressive case discussion in which more information is gradually released and student pharmacists must decide on a course of action. The students walk through the case and figure out what could have been done better to prevent errors. A simulated IPE in the fourth year has students deciding how to handle a situation where an error occurred and considering what processes could have been in place to prevent it.

The curriculum at Presbyterian College School of Pharmacy similarly focuses on communication and preventing errors. “Our P1 students take an Introduction to Pharmacy and Patient Safety course so they see it right out of the gate,” said Smith. “They learn about the role that the pharmacist has in protecting patient safety. We do a whole lab dedicated to medication errors. They practice SBAR communication to help remedy these errors. When I introduce the lab I tell them stories of errors I’ve made. Errors will happen—our job is to minimize the harm. A lot of things can go wrong on a shift but the main concern is that every prescription is right and safe.”

The therapeutics courses have an associated lab where students are presented with case studies. “In each of those modules they have a kill-harm station. We are showing them that these decisions will come up in practice and what those decisions will look like,” Smith explained. “When they can see a specific case, it really helps them understand. On rotations, we have really seen an increase in APPEs that are transitions of care. We’ve realized as a profession that during these times of handoff, these transitions really open up the possibility of errors, confusion or poor communication. Our students are actively involved in these transitions of care and ensuring that the patient understands the medications.”

Tools to Make Tweaks

The Alliance for Patient Medication Safety began as a 501(c)(3) organization to provide quality improvement resources and tools to pharmacies but since 2008 provides PSO services. PSOs grew out of the Patient Safety and Quality Improvement Act of 2005 passed by Congress. The ACT indicates that the quality improvement work and patient safety activities conducted by providers who work with a PSO are legally protected and not subject to discovery. The protections are to encourage healthcare providers to collect and analyze quality data. “We provide an error reporting portal so that a pharmacy can collect near misses, unsafe conditions and errors that reach the patient in order to find workflow and process breakdowns, or areas for improvement,” Modisett said. “The reported data are displayed in charts, graphs and spreadsheet form so that pharmacy teams can easily identify trends in a format that works best for them. Pharmacies can use this data in their staff meetings and discuss ways to improve how they operate that would reduce the risk of patient harm.”

The APMS PSO receives data from participating pharmacies, analyzes the data for alerts and aggregate trends and creates newsletters and safe practice recommendations for the pharmacies. The changes needed to improve safety processes in pharmacies can range from retraining to changing the physical space to altering the workflow. “We do offer the program as a resource for pharmacy schools to use,” Modisett said. “Some schools use it in their practice labs or use our CQI PowerPoint or our materials in their QA curriculum.”

Pharmacists should be at the table to help address quality and patient safety issues, not only those focusing on medication errors, in the institutional, ambulatory and community settings. Pharmacists’ ready access to patients help us have a unique perspective on their role in improving the quality and safety of care they receive.

Dr. Veronica Young

She continued, “We encourage the pharmacy team to continuously evaluate their operations and fine-tune their workflow. Pharmacies are very busy and complex systems; there is a lot going on between receiving the prescription and when the patient leaves the pharmacy. Each patient has a profile that needs to be updated for allergies, medication changes, insurance changes and reviewed for appropriate or duplicate drug therapy. We advocate that the staff works together as a team to evaluate what is and what isn’t working. The PSO shares lessons learned so that pharmacies learn from each other.”

Houston’s Hatfield pointed out that when a pharmacist knows all of the medications someone is on, understands the complete picture and can do medication therapy management, it can put a patient’s mind at ease. “One thing that happens is patients have so many different providers and by having all that information in multiple places, patients are doing a disservice to themselves,” she added. “Pharmacists can encourage them to get everything filled at one pharmacy. Finding a primary pharmacy for your filling spot so all of their information is coming through one provider/pharmacist. It’s good to have everything filter through one individual who is looking over everything—that’s something a pharmacist can do and should be encouraging patients to do.”

Empowering Patients

At The University of Texas at Austin College of Pharmacy, the journey to prepare student pharmacists to empower patients to seek quality care begins in year one. Medication safety is part of the core curriculum. Student pharmacists learn how and when to intervene and make recommendations to ensure that safe use of medications is being addressed. Patient safety in the broader context of quality improvement is integrated through the IPE curriculum. Concepts are introduced using active learning to first-year pharmacy students in interprofessional teams consisting of pharmacy, medicine, nursing and social work learners. “Our second-year student pharmacists are required to complete the IHI Basic Certificate in Quality and Safety with medical students and graduate nursing students,” said Dr. Veronica Young, director, Center for Health Interprofessional Practice and Education, and clinical professor, Pharmacy Practice Division, The University of Texas at Austin College of Pharmacy.

“Students from the three programs complete the IHI modules in the same sequence and timeline in preparation for a student-driven, online patient safety discussion forum in the fall and spring semesters,” she continued. “It is built to address specific programmatic needs among the three programs. In response to carefully crafted discussion prompts designed to encourage sharing of interprofessional perspectives, students dialogue in interprofessional teams to explore causes of healthcare errors and solutions.”

These earlier activities around patient safety and quality improvement prepare third-year student pharmacists to work on their required yearlong population health projects. “One key objective of this project experience is for students to gain real-world experience in addressing social determinants of health. Students learn the importance of reducing barriers to health,” Young noted. “Part of improving population health is to align it with community empowerment, specifically, engaging pharmacists to empower individuals and communities to have an active role in their own healthcare. This field-based experience prepares our future pharmacists with the skills, competence and confidence needed to truly be a part of this change to improve patient safety.”

In her research, Young works with community organizations to empower individuals to address patient safety. Working with the Louise H. Batz Patient Safety Foundation in collaboration with the City of San Antonio Head Start Program, “we find innovative ways to support families to be an active member of their own healthcare team to seek safe and quality care,” she said. “The other part of my research focuses on capacity building. I believe that while we can reach out to community members individually, it is more effective and sustainable to support capacity building efforts in response to needs identified by community organizations. Most of my work centers around building capacity of frontline staff such as community health workers to promote health and improve patient safety.”

I really think all pharmacists serve as stewards of medications, and we help decide when the benefits outweigh the risks and how we can minimize patient harm.

Dr. Mary Douglass Smith

She emphasized that student pharmacists should be trained in interprofessional teams to address patient safety including medication-related errors. “Pharmacists should be at the table to help address quality and patient safety issues, not only those focusing on medication errors, in the institutional, ambulatory and community settings,” she said. “Pharmacists’ ready access to patients help us have a unique perspective on their role in improving the quality and safety of care they receive.”

Presbyterian’s Smith echoed that sentiment. “Once you enter into our healthcare system it can be hard to navigate and it can be confusing,” she acknowledged. “I had one major health concern and even I felt lost as someone with high health literacy. Because pharmacists are so accessible, it’s really about taking the time to explain things to a patient and helping them understand the different steps. How do I get a referral to a specialist, prior approvals, things like that?”

While empathy and patience go a long way, Smith said it comes down to setting the highest possible standard for safety: “I really think all pharmacists serve as stewards of medications, and we help decide when the benefits outweigh the risks and how we can minimize patient harm.”

Jane E. Rooney is managing editor of Academic Pharmacy Now.