Last week I had the opportunity to participate in an IV Safety Safety Summit outside of Philadelphia. First let me congratulate the folks at ISMP for putting together what I thought was a well-run program and John Deadwyler for keeping us honest and on-track.
I had some observations:
- The group seemed to see a significant difference between what was ideal, from a safety perspective, and what was practical. That tension seemed to permeate the discussions. While I believe that that tension will likely always exist to some degree, it should propel us to ask what we could change about the way we work to relieve that tension, and to make safety practical.
- A lot of discussion seemed to revolve around what I would describe as evolutionary, incremental changes to tools and procedures currently in existence that ultimately seemed to involve throwing more bodies at the problem. It is my opinion that we have reached the end of the line on relying on human diligence and we need significant, revolutionary changes in the way we work if we want to move the needle on patient safety. Perhaps the most significant revolution in our thinking needs to be that we abandon the pharmacist-at-the-end-of-the-line-inspecting-everything paradigm. Industry did that over 25 years ago. I know that is a cherished model, but the number of things to inspect is too great, and human diligence is too frail to rely on that as a mechanism for safety.
- Mythology around USP <797> is alive and well; there were a couple of times when I thought Eric Kastango showed admirable restraint.
Lest there be any doubt, let me make my position clear. Safety is VERY practical, as is quality. When properly deployed, unproductive work gets replaced by productive work, and the amount of work to be done actually diminishes. What is minimally required, however, is that safety, and quality not be negotiable. The challenge must therefore be not to figure out how to avoid best practices, but how to make those best practices practical. From my point of view, that is likely to require the application of technology.
Note that I am NOT saying just any technology. The technology itself must fullfill a useful purpose. But, knowing human frailty, that application must facilitate the culling out of the exceptional issues that require human intervention (as opposed to requiring human intervention on everything), so that human capital is spent on solving the issues only humans can solve. Allen Flynn challenged us on that very idea a couple of years ago1. It is a challeng to which we have not yet arisen.
So, if you had to enumerate the best, the safest practices that should exist in your IV room, what would they be? And, having enumerated them, how are you planning to make them happen?
Let me know what you think.
1 Flynn AJ Opportunity cost of pharmacists' nearly universal prospective order review Am J Health-Syst Pharm April 1, 2009 66:668-670
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