The ethics of a “Just Culture”
http://drugtopics.modernmedicine.com/drug-topics/news/ethics-just-culture
This is a article by Attorney/Pharmacist Ken Baker dealing with errors/mistakes in the pharmacy environment..
This particular statement really hit a nerve… especially when I have heard other Rph’s talk about their work environment
From the article:
There are a few medication errors, however, for which there needs to be blame assessed and for which punishment is appropriate. Very occasionally the root cause is not a process flaw or a workflow difficulty. Sometimes the root cause is the pharmacist or pharmacy technician’s at-risk behavior. At-risk behavior may be multi-tasking or trying to fill too many prescriptions at one time.
If a RPH/tech is attempting to meet production metrics… it could be considered “risky behavior” and financial costs of any resulting med errors could come down on your shoulders for acting unprofessionally ..
Filed under: General Problems
Great analogy! I often tell customers who want us to “rush” more than we already are….we can get it to you faster if you don’t care what’s in the bottle. The general public does not really care, as long as the error in not their prescription. It is no surprise that our pics are mean and abusive. The other day I was chastised for taking too long to give an 11 yr old a Tdap because the queue was building up. Let’s see….I am injecting a biological into the arm of an adolescent and I am not supposed to take extreme care?? OK…..
In his prior commentary, our friend Kenneth seems to want to completely criminalize Human error committed by pharmacists. In June, he seems to frame errors as the result of loyalty to the company over duty to the patient. I don’t know WHAT planet he is from and don’t *even* get me started on the logical fallacy of that premise.
At least in July, he alludes to the fact that maybe, just MAYBE workplace conditions contribute in some small, minuscule way.
Now I’m sure many pharmacists are what cognitive neuropsychologist call “super-multitaskers,” Those statistical outliers who are less susceptible than most people to cognitive impairment while performing tasks in the face of distractions and interruptions. Unfortunately, I am not one of those people.
Here’s my analogy for piling Wall Street-driven quotas on those entrusted with public health and safety: Imagine yourself in a taxicab navigating through the busy chaotic streets of Manhattan. The driver of this cab is employed by a huge publicly-traded company that charges only $2 per ride and dings the driver if they fail to deliver you to your destination within 15 minutes,regardless of traffic conditions or your where you demand to be taken. The cab’s dashboard is equipped with a video display streaming company-mandated learning modules that the driver is trying to complete by the end of his/her shift. Not only that, but the driver is also required to make outreach calls to potential customers from a cell phone during your ride as well as respond to any text message within 30 seconds that appears on that phone, whether or not the cab is on the road.
Oh! And the safety inspection of this vehicle was performed in the middle of the food court in a crowded mall by a company mechanic who was required to immediately stop, greet, and give free car advice (or directions to the bathroom) with “laser focused attention” to anyone who approaches.
“But,” you may ask, “Shouldn’t texting and talking on the phone while driving be illegal? I seem to remember a term bandied about- Hmmm, what was it? Something like ‘inattention blindness.’ Oh, wait! It IS illegal to text while driving.”
“And don’t they estimate a 12% error rate for every interruption during a complex task?” Oh don’t worry! That mechanic was told not to view greeting onlookers as an interruption during a safety check. I’m sure the brakes are fine.
Would you want to step into that cab?
I read the entire article, but I could not find anything in it that I considered useful. An error can have many causes, and probably does have multiple factors involved. The case of Eric Croop is a prime example. The main cause of the error was the distracted technician. The next fault was the hospitals procedure for doing IV’s, and the last fault lay with Eric. But, he got all the blame. The technician was not prosecuted, nor was the hospital fined because of poor procedures that they had in place. In today’s pharmacy, there is, at times, a scene of near chaos. Customers complaining….equipment going down…phone constantly ringing…people on cellphones talking like the other party is hard of hearing…and rx’s filling up the fill que to be filled. The environment is more like a bar than a place where critical work is done. As Joe says, the hours are long and the environment is stressful. The concept of putting all the blame on the pharmacist is ridiculous. The BOP’s need to wake up. They need to look, not just at the pharmacist, but at the entire pharmacy, such as techs, distractions, pharmacy design, and corporate procedures.
Stay Tuned…..my case addresses these issues and I have the proof. Until the BOP gives a SH**’, these errors will be bought off with gift cards and fines. Another area of concern is the tired RPH….working 14 or more days 12-14 shifts also spells disaster… I recently heard about a RPH working 24+ hours….the metrics don’t go away so you know where the focus is. This takes me back to a statement made by a PDM…IF YOU GO RED YOUR DEAD….in most cases when timing Rx’s if you don’t go RED the PATIENT could be DEAD!!!