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A Medication Safety Officer’s Perspective on Safely Managing Refrigerated Medications: Week Five

Posted on Aug 16, 2019 by Jessalynn (White) Henney, PharmD

Safely Managing Refrigerated Medications Series_ Week 1-1

This week, we are continuing our Medication Safety Officer blog series on managing refrigerated medications. Each week, Network Medication Safety Officer, Jessalynn Henney, PharmD, will be answering questions related to the safety and security of storing and handling refrigerated medications. This week, we are discussing how Pharmacy Directors, Medication Safety Officers, and other healthcare personnel involved in the handling of refrigerated medications can improve refrigerated medication management from a safety and security perspective.

How can pharmacy leaders improve refrigerated medication management?

Start with discovery! I recommend using all three of these tactics to uncover current state, challenges, and patient risk affiliated with any process BEFORE creating a potential solution.

Tactic #1: Be inquisitive and ask questions

  • The goal is to understand the general overview and steps involved with the process. Answers should come from both standard work documents (i.e. protocols, procedures, policy, etc.) and people who are ACTUALLY doing the process. When asking those who do the process, make sure a variety of people (i.e. skill level, time within the organization, shifts, etc.) are queried to discover process consistency or deviations.
  • When inquiring about the steps of the process, it is important to understand the “why’s” and “how’s”. Questions to help discover this information could be “How did they know to do this step?” or “Do they find this step of the process valuable?”. This helps to understand if best practices are included within standard operating procedure documents or being learned through tribal knowledge from peers in their department.
  • Help to evaluate potential error risk. Questions to determine this include: How likely does this occur? If this error does occur, how likely will it be detected? If not detected, how severe are the consequences if it reaches the patient?
  • Include ALL members/stakeholders involved within the process. While it is intuitive to include technicians and pharmacists, do not forget about nursing, respiratory therapists, or other caregivers that retrieve items from the ADC.

Tactic #2: Observe the actual process

  • How often are you able to physically see the refrigerators outsides of the pharmacy? Remember – pictures can say 1,000 words.
  • Provides an opportunity to confirm responses from questions and see if supporting process documents match the actual process.
  • Helps to understand the barriers, workarounds, and process deviations happening with in the process.
  • Allows for a fresh set of eyes to analyze/review the process.

Tactic #3: Utilize data and outside resources

  • Data can help confirm stories/information – Ideas may include ADC transaction reports, voluntary reported events, or tallying how many phone calls/electronic messages are sent regarding a “missing” medication.
  • Utilize resources from safety organizations, such as ISMP and CDC, to ensure incorporating best practices.
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Jessalynn (White) Henney, PharmD

Written by Jessalynn (White) Henney, PharmD

Dr. Jessalynn (White) Henney, PharmD, currently serves as the Medication Safety Director at Community Health Network (CHNw). Through multidisciplinary teams, Dr. Henney oversees the strategic management of medication safety, for both acute care and ambulatory care services, focusing on all steps of the medication use process.

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