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Risk Management In Hospital Pharmacy Practice

Risk is the potential that a chosen action or activity (including the choice of inaction) will lead to a loss (an undesirable outcome).

Risk is ubiquitous in all areas of life and risk management is something that we all must do, whether we are managing a major organization or simply crossing the road.

Risk management is the identification, assessment, and prioritization of risks (defined in ISO 31000 as the effect of uncertainty on objectives, whether positive or negative) followed by coordinated and economical application of resources to minimize, monitor, and control the probability and/or impact of unfortunate events or to maximize the realization of opportunities.

In ideal risk management, a prioritization process is followed whereby the risks with the greatest loss (or impact) and the greatest probability of occurring are handled first, and risks with lower probability of occurrence and lower loss are handled in descending order.

In hospital pharmacy setting, there are 4 categories of risks with respect to whom or what will be directly affected:
1.The Patient
2.The Pharmacists
3.The Hospital
4.The Environment (if applicable)

It is worthy to note that the effects of a risk may actually have multiple victims. For example, the event of a severe dispensing error may result to morbidity for the affected patient, who may decide to take legal action against the hospital, and against the dispensing pharmacist. In the end, the resultant outcome could be: —The death of the patient, Financial constraint to the hospital in payment of damages, Damage to the hospital’s reputation, Lack of faith in the hospital by the population thus resulting to many clients looking for alternative health care providers, Dip in clientele volume will lead to drop in income for the hospital, The dispensing pharmacist may be reprimanded by the hospital, The hospital may have to spend a lot more on efforts to gain back the trust from the population.
However this catastrophe could have been easily avoided if the management had made efforts to mitigate against such a risk to as low a level as possible by just working on the possible root causes of dispensing errors.
Dispensing Errors
Adverse Drug Reactions
Handling Drugs incorrectly —
Risk Of Dispensing Errors: Pharmacists are highly skilled professionals delivering essential health care, but mistakes by pharmacists and other health care professionals can occur with striking frequency. Among pharmacists, an error can also take many forms and pharmacists’ errors can be classified as mechanical or judgmental.
A mechanical error is an error in the preparation and processing of the prescription, while a judgmental error is one of discretion in counseling, screening, or patient drug monitoring.

Mechanical errors include dispensing the wrong drug, dosage form, directions, quantity, or strength or dose. Judgmental errors include improper or no counseling, failure to detect drug interactions, and inadequate drug use review. The most common error reported is the selection of the wrong drug. While errors may not always have severe consequences, studies have concluded that up to 3% of dispensing errors by inpatient hospital pharmacies are potentially serious.
According to a survey by Massachusetts Board of Registration in Pharmacy on Medication Error Study, the following were listed as the most common causes of dispensing errors by pharmacists: •Too many telephone calls (62%) • Overload/unusually busy day (59%) • Too many customers (53%) • Lack of concentration (41%) • No one available to double-check (41%) • Staff shortage (32%) • Similar drug names (29%) • No time to counsel (29%) • Illegible prescription (26%).
So how is the Risk of Dispensing Errors managed? —Use of a “triple check plus two” system in which the medication is checked three times: when it is taken off the shelf, when it is placed in the container, and when all drugs in the prescription have been packaged. —Counseling provides many benefits to the patient and is also a particularly effective measure in reducing errors. Many errors (e.g., wrong drug) are detected during a counseling session. a “show and tell” technique in which the patient is shown the drug while the pharmacist asks three key questions: 1) What did the physician tell you the drug is for?; 2) How were you told to take the medication?; and 3) What directions did the physician provide for taking the medication? The pharmacist can then compare this information with the drug and label and recognize discrepancies. —Errors can also be prevented by reducing pharmacist stress and patient pressure, including providing a comfortable waiting area. —not storing drugs with similar names near each other. —taking the prescription or label to the shelf when retrieving the drug instead of relying on recall. —The US FDA recommendations regarding drug name confusion include encouraging pharmacists to separate similar drug products on pharmacy shelves and encouraging physicians to indicate both brand and generic drug names on prescription orders, as well as the drug’s indication, which provides the pharmacist with several cues to prevent confusion.
Other recommendations include the elimination of handwritten prescriptions to avoid problems associated with illegible or ambiguous handwriting.
Risks that will affect the pharmacist: Hospital pharmacists are constantly exposed to a variety of risks ranging from occupational hazards to patient interactions taking ugly turn, to risk of breakdown in well-being as a result of chronic heavy workload. Some of the potential risks many pharmacists on a daily basis include: —Physical Injuries ranging from mild to severe or even fatal. —Electrocution from use of electrical equipment —Exposure to hazardous drugs or chemicals during handling or preparation such as dust of drugs during compounding or spillage of a radiopharmaceutical. —Assault by a hot tempered patient or even a mentally unstable one —Allergic reactions to one or more of the drugs or stock handled in the pharmacy —Contacting contagious diseases from infected patients

Pharmacist in the nuclear medicine taking necessary precautions with a Geiger-Muller counter. Is the counter due for recalibration?
A Pharmacist in the counseling cubicle 1-on-1 with a patient. Exposed to risks of assault or even robbery.

So how the risks that may endanger the pharmacist managed?

—Pharmacists should be provided with protective gear such as gloves and masks when mixing and compounding drugs and radiopharmaceuticals.
—Ensure proper storage facilities for radiopharmaceuticals
—Providing proper ventilation can reduce the risk of catching air-borne illnesses.
—Pharmacists perform repetitive motions such as filling pill bottles, opening and closing registers, filling out many documents. Asides the fact that many stand for long, and work long hours, the overall well-being of the pharmacist can be aided by procurement of specific tools that automate tasks such as pill dispensing can reduce repetitive strain injuries and Carpel-Tunnel syndrome.
—Providing training for staff in recognizing and managing hostile and assaultive behavior.
—Implementing security devices such as panic buttons, beepers, surveillance cameras and alarm systems.

—Risks that may affect the hospital
Some of the risks that are described in this category may present themselves as:
1: Risks to the Hospital Facility.
2: Risks of Legal Actions against the Hospital.
3: Risk of Terrorist or Hostile situations.

Once risks have been identified and assessed, all techniques to manage the risk fall into one or more of these four major categories:
Avoidance (eliminate, withdraw from or not become involved): This includes not performing an activity that could carry risk, but also means losing out on the potential gain that accepting (retaining) the risk may have allowed.
Risk Reduction (optimize – mitigate): involves reducing the severity of the loss or the likelihood of the loss from occurring. For example, sprinklers are designed to put out a fire to reduce the risk of loss by fire. This method may cause a greater loss by water damage and therefore may not be suitable. Halon fire suppression systems may mitigate that risk, but the cost may be prohibitive as a strategy.
Risk Sharing (transfer – outsource or insure): sharing with another party the burden of loss from a risk, and the measures to reduce a risk.
—Retention (accept and budget): Involves accepting the loss from a risk when it occurs. This is a viable strategy for small risks where the cost of insuring against the risk would be greater over time than the total losses sustained.

—Hospital Pharmacists have always expressed potentials of being ideal risk managers. In the daily professional life of a hospital pharmacist, he/she instinctively is on the look out for potential hazards to their patients via scrutiny of prescriptions for drug interactions; mitigates against the risk of running out of stock of essential drugs; secure our safety when handling certain medications; and always ensures all professional actions are by the book.
—However the pharmacist has a much bigger role to play. The pharmacist could be an integral part of the setup of the Risk Management Team. This team will take charge of handling the entire Risk Management Processes within the hospital and the pharmacist can be resourceful in providing key information that will be of ultimate benefit to the Patients, The Pharmacists, other Health Care Providers in the hospital, and the Hospital itself.

—Risk management is the identification, assessment, and prioritization of risks followed by coordinated and economical application of resources to minimize, monitor, and control the probability and/or impact of unfortunate events.
—Many fields including Health have numerous risks that are inherent and it is of utmost importance that these risks be managed appropriately. Even though it is impossible to completely eliminate a risk, the concept of risk management is help reduce such risks to the barest minimum.
—In Hospital Pharmacy practice, the pharmacist is exposed to various risks. Some risks can be simply managed, whereas some risks immediately require special attention and protocols to be mitigated. Therefore concept of Risk Management in Hospital Pharmacy Practice cannot be brushed aside by pharmacists and left for Aliens in the field of pharmacy practice to manage risks they do not have to face on a daily basis.

—ISO/IEC Guide 73:2009 (2009). Risk management — Vocabulary. International Organization for Standardization.
—ISO/DIS 31000 (2009). Risk management — Principles and guidelines on implementation. International Organization for Standardization.
—Crockford, Neil (1986). An Introduction to Risk Management (2 ed.). Cambridge, UK: Woodhead-Faulkner. p. 18. ISBN 0-85941-332-2.
—Senge, Peter (1990). The Fifth Discipline: The Art and Practice of the Learning Organization. Doubleday. ISBN 0-385-51725-4.
—U.S. pharmacy errors: unreported epidemic? ABC News. Aired March 29, 2007. Accessed October 1, 2008.
—Medical Errors: The Scope of the Problem. Fact sheet. Rockville, MD: Agency for Healthcare Research and Quality; 2000. Publication No. AHRQ 00-P037. Accessed October 1, 2008.
—Reducing and Preventing Adverse Drug Events To Decrease Hospital Costs. Research in Action, Issue 1. Rockville, MD: Agency for Healthcare Research and Quality; 2001. AHRQ Publication No. 01-0020. Accessed October 1, 2008.
—Guernsey BG, Ingrim NB, Hokanson JA, et al. Pharmacists’ dispensing accuracy in a high-volume outpatient pharmacy: focus on risk management. Drug Intell Clin Pharm. 1983;17:742-746.
—Peterson GM, Wu MSH, Bergin JK. Pharmacists’ attitudes towards dispensing errors: their causes and prevention. J Clin Pharm Ther. 1999;24:57-71.

Credits: Pharm. Funmilola Oshinowo

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