APhA 2025: Strategies for Reducing Errors in Community Pharmacy Settings

Pharmacy Times® interviewed Matthew Grissinger, BSPharm, director, education at Institute for Safe Medication Practices (ISMP), on his presentation at the American Pharmacists Association (APhA) Annual Meeting & Exposition.

Grissinger discussed 3 new ISMP best practices for community pharmacies: managing patient weights for accurate dosing, improving medication return-to-stock processes, and preventing vaccination errors. He emphasized the importance of proactive risk identification through self-assessments and staff involvement. The conversation highlighted the need for comprehensive strategies to reduce medication errors, including observing processes and creating a culture of safety. Key recommendations included engaging staff, using targeted worksheets, and addressing potential risks before they lead to mistakes.

Pharmacy Times

What are the 3 new practices added to the ISMP 2024-2025 Targeted Medication Safety Best Practices for hospitals, and why do you think these areas were prioritized?

Matthew Grissinger

There are 3 areas or 3 items we added to our targeted best practices for community pharmacy. First one deals with patient weights, and that's we’re talking about, say, pediatric population, we get an antibiotic dose, but you need to verify that dose based on their weight. So, this best practice revolves around community pharmacies, obtaining the weight, having processes to update the weight, and to work with prescribers to get that weight sent over electronically every time there's a prescription for the dose that may be based upon the patient's weight.

The second-best practice revolves around the process of returning to stock, meaning you fill some prescriptions on a pharmacy, they're not picked up, so we're going to put them back into stock. A lot of errors have happened because of that process. Sometimes people have poured the return to stock bottle into an open manufacturers bottle, or into some technology machine, versus having a process to clearly label it with a barcode and drug name, being able to use it again, prioritizing its use in a process so it doesn't get mixed up with other drugs as well.

Lastly, just broadly about vaccinations, about errors that have happened with vaccines. We all understand the importance of vaccinations — I think we really do understand that when errors happen with vaccinations, we're talking about patients who are not getting a vaccine they intended to get. Meaning they're not immunized for what they thought they were. There is a lot of variety of types of errors. There are mix ups between pediatric and adult formulations, wrong route stuff. You have parents bringing multiple siblings in and mix up between the siblings — there's some examples of vaccine errors. So that best practice is talking about all the processes with storing them, administering them, and, most importantly, getting the patient involved in the process too, so they understand what they're getting and why they're getting it for.

Pharmacy Times

Can you describe a specific method you would use to assess medication safety practices in a community or hospital pharmacy setting. How would you identify potential gaps?

Grissinger

There are a couple ways to identify risk. We'll talk about risk identification first. So, pharmacies really need to start looking at what type of things may not be working in your pharmacy. For example, when you talk about risk, we're talking about, is there variability in your processes? Are people doing workarounds, as an example> How often, as another example, you have someone at the cash register giving out a medication, is that person at the register using 2 patient identifiers? And are they doing it all the time, or how much. The ways to assess these types of issues are many folds. I would say the best thing, first off, is being proactive. We don't want to wait for an error to happen then react to it. So proactively, one thing we always recommend is doing something like a self-assessment by having a pharmacy evaluate their processes, whether they are being done or not, and how often they're being done as well. A great tool we have is based on these targeted best practices is a worksheet for our targeted best practices that allow pharmacies to download and assess all the elements of the best practices, to see where they sit with that and whether I need to implement something or not. I would add to that is this is, really should be a pharmacy approach, not a pharmacist approach. We need the technicians involved. Even people are going to cash register leaders, pharmacy managers, even district managers involved in this process so that staff sees that leadership supports them, and we give everybody a chance to have a say or give input into what they see is happening and not happening your organization.

Pharmacy Times

How would you measure the success of a change management strategy implemented to improve medication safety. What key performance indicators would you track?

Grissinger

Going back to what we just discussed about assessing yourself, again there's variability in what we're doing with our processes. We talked about doing self-assessments, and maybe another way is saying using observation to see if someone's doing something or doing a workaround. So, what we want to measure are these processes. We're going to call them process measures, right? The key thing to understand here this is something that we don't have to gather dozens and dozens of data points. We're talking using sampling, maybe observe something 10 times. We'll go back to the cash register example, as one issue, observing 10 interactions at the register, and how many times is that happening? So, you want to think about those type of any process that's supposed to happen, and is it happening? Is it getting done? Are people again, doing workarounds or other at-risk behaviors? But I'm going to add something important — measuring it is great, but it still doesn't tell you why it wasn't getting done. Let's go back then to talking to staff to see what would be happening. So, you want to measure your processes.

I'm not sure I would say there's key indicators. I'm thinking these last steps in the processes in pharmacies, that there's probably a lot of indicators, including from getting the original prescription by a verbal telephone order, whether that's written down or read back down to patient counseling. Then we dispense a patient a drug to a patient. Are they getting counsel on that? There's a lot of things to be measured through the processes. I consider many of those key indicators.

Pharmacy Times

Beyond the ISMP best practices, what are some additional strategies you would implement in your pharmacy to foster a culture of medication safety and encourage staff to report and learn from errors?

Grissinger

I would say, even going back to we talked about identifying risk and being proactive with that, probably the easiest way to do that is ask your staff. Just ask them. You'd be surprised how many times people have concerns or know things aren't going well or can see something that's going to happen and go wrong, but they don't feel like they can speak up. To improve the culture is you need to involve them and let them be able to come to you and listen to people who work for you and hear about the concerns, ask them about what their concerns are or where do they think the next big medication error is going to happen. Getting them involved, knowing that you want to hear their opinion and their thoughts that will improve your culture, right? So, getting the staff involved in more than just filling prescriptions, and try to have them help looking at processes of what's getting done. Have them feel that their opinions mean something to them.

Sometimes it depends too where they came from, like they could have worked at a pharmacy where it was just a poor culture. They come to you now and you have a great culture, they don't know that. Part of the orientation process is, is we need to hear your voice. We want to know what concerns you, because I'd rather fix something proactively than wait for an error to happen to fix it reactively.