Becoming a Certified Professional in Patient Safety—A Pharmacist's Perspective
Board certification in any field signifies competence. Your degree, work experience, and technical skills are not necessarily an objective way to assess competence in the field of patient safety. However, the National Patient Safety Foundation (NPSF) certification exam is a universal standard recognized throughout the nation. As a pharmacist working in patient safety and quality, I felt compelled to become a Certified Professional in Patient Safety (CPPS). This was an easy decision, since it augmented my responsibilities and added to my qualifications.
The exam covers culture, leadership, risk identification and analysis, data management, system design, mitigating risk, human factors analysis, and external influences on patient safety, error science, and full disclosure. The test is meant to be completed by professionals who interact with the areas of patient safety and quality regularly. As soon as the certification became available, I took the test, which I found to be a practical reflection of the skills needed to work in patient safety. There are currently more than 900 CPPSs in the United States and overseas, with 60% coming from a nursing background.
As my institution's medication safety officer, it is vital that I listen to the health care team when they explain the events that led to the medication error. I focus on increasing reporting of medication errors and mitigating future risk. When I started at Sinai Health System 6 years ago, I focused on high-alert medications: anticoagulants, opioids, and insulins. I was pleased that, after a few years, the frontline pharmacists matured into an army of medication safety officers—I was no longer shouldering the entire organization's medication safety work myself. The decentralized pharmacists would bring issues to my attention and say, "This is a patient safety issue."
I participate in two comprehensive unit-based safety program (CUSP) teams (in Labor & Delivery and Pharmacy), which focus on optimizing patient care and increasing teamwork among members. The Labor & Delivery CUSP team focuses on communication and documentation. Problems in these two areas are the most cited reasons for medical errors. We have improved communication with the use of SBAR (situation, background, assessment, recommendation), yet medical errors continue to occur. We have implemented several technologies such as computerized provider order entry, barcode medication administration, smart pumps, and IV workflow software. These too have helped, but they have certainly not abolished all medication errors. After participating in several root cause analyses, I came to realize that communication among the patient care team is the root cause of most errors.
My goal is always to be transparent and communicate medication errors to my staff. To guide my efforts, I describe actual errors, and several resources that are well known in medication and patient safety such as materials put out by the Institute for Safe Medication Practices, ECRI's list of top 10 safety hazards, and AHRQ's Hospital Survey on Patient Safety Culture. I read and apply several of the best practices featured in the articles these organizations publish. At my institution, I look at the results of our AHRQ Hospital Survey on Patient Safety Culture and develop an action plan based on the dimensions on which we did poorly.
One method that I utilize is storytelling, and I find it to be quite effective. When a patient falls victim to a medication error, the employees may experience heightened emotions and symptoms of trauma as they reflect on the error. Sometimes I share well-publicized medication errors, including heparin errors (1,2), the NECC incident (3) and the case of an antiseptic switch that resulted in a woman's death.(4) In the latter case, a 69-year old woman with a brain aneurysm died when she was mistakenly injected with an antiseptic rather than the intended radiologic marker dye. It was determined that the brown antiseptic had recently been changed to a clear colorless solution, which looks exactly the same as the dye. The new antiseptic was placed in an unlabeled container, similar to the dye container.
Having certification heightens the health care provider's awareness of potential vulnerabilities in their workflow. CPPS professionals are able to be more critical in dissecting processes and improving patient safety.
They are more likely to read about medical errors and reflect on remedies to prevent errors at their sites. CPPS professionals are more familiar with root cause analysis, failure mode and effect analysis, and the benefits of using these tools. The CPPS designation enables the provider to utilize poignant scenarios to reinforce patient safety everyday at work. Sharing stories makes the staff emotionally engaged and they repeat the stories with other members that were absent. They are truly affected by the tragedies that occur in the literature.
One of the advantages of CPPS certification is that it forges a tighter connection between practitioners and the NPSF. I would encourage everyone to attend the annual NPSF Congress as a way to celebrate each other's progress in working to improve safety. Being surrounded by other professionals who prioritize patient safety in their work and operations motivates attendees to go back to their institutions and implement best practices to improve safety. Walking through the poster session, participants can read about how other hospitals have tackled problems, and they will receive copies of the tools and materials utilized by the presenters and their institutions. With limited resources and personnel in most hospitals, the poster session equips attendees with essential tools.
It's time for a change in health care. It's time for interprofessional, patient-centered thinking that provides high quality and safe patient care. We have all heard the adage "knowledge is power." Achieving the distinction of a certified professional in patient safety is a powerful tool for individuals interested in becoming a leader in health care.
Zahra Khudeira, PharmD Medication Safety Officer Sinai Health System Chicago, IL
1. Arimura J1, Poole RL, Jeng M, Rhine W, Sharek P. Neonatal heparin overdose-a multidisciplinary team approach to medication error prevention. J Pediatr Pharmacol Ther. 2008;13:96-98. [go to PubMed]
2. Phend C. Heparin overdose in three infants revisits hospital error issues. MedPage Today. November 26, 2007. [Available at]
3. Eichenwald K. Killer pharmacy: inside medical mass murder case. Newsweek. April 16, 2015. [Available at]
4. Terrible tragedy—and powerful legacy—of preventable death. Seattle, WA: Virginia Mason Institute; March 26, 2014. [Available at]