PATIENT SAFETY

as a means of increasing patient safety awareness and to provide resources to patients would be ideal, as the campaigns brand recognition is already established. Therefore, three Task Force members volunteered to work with MPA staff on expanding the Thats My Pharmacist campaign to encompass patient safety efforts. As part of this effort, patient medication cards were developed, which included questions the patient should ask his/her pharmacist, such as what a medication is used to treat and what to expect. Several Michigan pharmacies made this postcard available to patients in the fall of 2012. Health Care Professional Education The Task Force spent a great amount of time discussing strategies related to health professional education. In addition to the previously described resource center, three other safety-enhancing strategies were identified specifically for health care professionals.  Patient Safety Certificate Program. A project assigned to and discussed by the Task Force was the development of a patient safety certificate program. The Task Force agreed that a certificate program, geared toward pharmacists and technicians, should be promoted to the MPA membership. A subgroup was formed to research what other programs already exist and the Task Force recommended that a survey be conducted to determine the memberships level of interest.  Mandatory Safety Continuing Education. The Task Force made a recommendation that one hour of continuing education (CE) on the topic of patient safety, be required of every pharmacist during each licensing cycle. This is not a new concept, as five states have already mandated patient safety CE as a requirement for licensure renewal.  Annual Convention Safety Track. The Task Force recommended that MPA provide a safety track at the 2013 Annual Convention & Exposition. As a result, several programs were offered during the Convention, including continuous quality improvement, the role of the technician, human factors and medication errors, each as they relate to patient safety. Access and Exchange of Health Information The Task Force held many discussions focusing on access to health information. The focus was on what pieces of information would be helpful to a pharmacist in practice, including data such as diagnosis, other medications and laboratory values.
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Developing Strategies to Improve Patient Safety

Patient safety was identified as a key strategic issue of Michigan Pharmacists Association (MPA) in 2011. As a result, the Patient Safety Task Force was formed and charged with developing strategies to promote patient safety. Meetings of the Task Force began in October 2011 and continued through September 2012. Subgroups were formed to work on specific strategies, some of which are still active today.
By MICHAEL CROWE
Pharm.D. at their local pharmacy. Overall, the groups focus was on a patient safety resource center and the Thats My Pharmacist campaign.  Patient Safety Resource Center. A web-based patient safety resource center was identified as a top priority during MPAs 2012 strategic planning retreat. This project was charged to the Task Force and, in response, the group as a whole brainstormed several components to be included in the resource center. The group recommended that the resource center have a public-facing page, which links out to patient-specific and health care professional-specific pages. Because this resource center will be based online, and MPA is currently in the process of redesigning its Web site, seven Task Force members volunteered to serve on a standing workgroup to consult with MPA moving forward.  Expanded Thats My Pharmacist Campaign. It was decided that utilizing the Thats My Pharmacist campaign

Strategies of the MPA Patient Safety Task Force

During the first meeting of the Task Force, members identified a multitude of strategies for improving patient safety. The group agreed that each of these strategies could be organized into one of five broad categories: patient education and communication, health care professional education, access and exchange of health information, just culture environment and pharmacy workflow. Moving forward, time was spent refining what actions could be taken, and what recommendations would be made within each of these categories. Patient Education and Communication Initial ideas of the Task Force for patient education and communication included spreading awareness through letters to the editor and social media, enhancing pharmacist education given to patients, and physical resources that could be distributed to patients

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Members of the MPA Patient Safety Task Force

Mike Crowe, chairman Larry Wagenknecht, MPA staff liaison Tim Arnold Rose Baran Denise Bluhm-Heise Mary Burkhardt Eleni Butzin Paul Chludzinski Ray Dorhout Angela Faszczewski Lynn Glasser Joe Leonard Dan Lobb Mike Major Doug Miller Paul Miller Carol Raznik Sarah Oster Greg Pratt Pat Quinn Brenda Ruhlman Tim Stiff Kevin Szyskowski Bill Walker

 HEDIS Measures Improvement Pilot. The timeliest opportunity related to this topic was involvement in a pilot project with HealthPlus of Michigan. The goal of this pilot was to improve Healthcare Effectiveness Data and Information Set (HEDIS) measures by providing additional patient-specific health information to pharmacists as well as compensation for successful interventions. The Task Force has provided four members to serve on HealthPlus planning Committee for this pilot. During the first meeting, diabetes was identified as an initial area of focus, and adjudication software soft edits were selected as the mode of sharing patientspecific health information. In the case of diabetes, pharmacists will receive a soft edit message for diabetic members needing their A1C or LDL drawn. The pharmacist will then provide education regarding the needed services to these members. As of October 2012, HealthPlus has partnered with a select group of independent pharmacies to perform interventions in patients with diabetes. As the success of the initial interventions is evaluated, the pilot is expected to expand to other pharmacies and other disease states. This evaluation process was tentatively set to take place by the end of the first quarter of 2013, during which the Task Force planning Committee members would continue to provide assistance. Just Culture Environment To refine strategies falling under just (nonpunitive) culture, Task Force members were electronically surveyed between meetings to prioritize culture and safety ideas identified during the first Task Force meeting. After prioritization and a follow-up meeting, the Task Force has made the following recommendations to the MPA Executive Board.  Modification of Public Health Code to be Less Punitive. It was the consensus of the Task Force to recommend to the Executive Board that the Association support legislation to create a less punitive environment by establishing a mechanism for action taken against pharmacists licenses, a process similar to a drivers license, and be graded based on the impact the causative act

has on the patient.  Promotion of the Institute for Patient Medication Safety and Pharmacist Peer Review. The Task Force concluded that MPA should continue to assist in keeping the Institute visible to the members. This could be accomplished by sending a fax blast about the Institute, highlighting the benefit to the pharmacist and emphasizing the confidentiality of the information. By doing so, MPA would be promoting the value of self-reporting.  Continued Support of Licensure and Certification of Pharmacy Technicians. The Task Force recommends that MPA continue to support the legislation that will require licensing and certification of pharmacy technicians. The Task Force further recommends that MPA encourage pharmacists and pharmacies to have their technicians become certified, even though it is currently not mandated. Pharmacy Workflow The issue of pharmacy workflow and its relation to patient safety was one of the most difficult to address. Not only is workflow subject to the physical layout of each pharmacy, it is also subject to the operating procedures already established by each pharmacy.  Workplace Stress Management Education. One commonality identified in nearly all practice environments was stress due to the many requirements of pharmacists such as prescription fill rate metrics, immunizations, consultations and refill calls. The Task Force, therefore, recommends that MPA provide a CE program (possibly a workshop) on best practices to handle pressure and stress in the workplace to enhance patient safety. Tools that help decrease workplace frustrations should also be promoted (e.g., Simplify My Meds from the National Community Pharmacists Association).  Pediatric Oral Compounds Standardization. A niche area within the category of pharmacy workflow, in which the Task Force will continue to contribute, is standardized formulation of pediatric compounded oral liquid medications. Jim

Stevenson and the University of Michigan are currently undertaking a Food and Drug Administration grant-funded research and process improvement project. It is a statewide collaboration to standardize compounded oral liquids. The four phases of the project are to survey pharmacies, analyze the results and develop standards, disseminate the standards and measure their impact.  The Task Force first provided assistance by reviewing the survey and providing feedback, and providing suggestions for the projects Committee members. In late September, the project Committee held a very successful meeting at the MPA headquarters. During this meeting, the project outline was presented, the results of the baseline survey were discussed and worksheets on 160 different target medications were handed out. Many of these drugs were being compounded in upward of 10 different formulations. Therefore, the group then established principles for what conditions should exist to define a standard concentration and conducted a preliminary review of the 160 medications, selecting the best possible formulations. Examples of these principles included having a published formulation, having a stability of at least 30 days, being relatively easy to compound, and having a formulation that uses readily-accessible components.  Project Committee leaders are currently doing background work on the potential standard concentrations, determining whether they meet the principles that were established in the meeting. Once this is completed, a second meeting will be held to try to finalize a proposed list of standards, which will then be circulated for comment to a more broad population of pharmacists, physicians and other stakeholders. This is anticipated to be completed the first quarter of 2013. After establishing the standard concentrations, the project will then move into the dissemination phase: working with MPA to communicate these standards and encouraging all pharmacies in the state to adopt them in the interest of improving patient safety.

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