The power of Total Quality Management
The first directive of the Pharmacists’ Code of Ethics reads: “A pharmacist respects the covenantal relationship between the patient and pharmacist.”1 A covenant is generally defined as an agreement. Common synonyms for covenant are contract, commitment, guarantee, pledge, and promise.2
Ethically, if not legally speaking, pharmacists and their patients enter into what lawyers call a unilateral contract — an act by a patient balanced by a promise by the pharmacist. As the APhA website explains it, “... a pharmacist has moral obligations in response to the gift of trust received from society. In return for this gift, a pharmacist promises to help individuals achieve optimum benefit from their medications …”1
If the pharmacist is to optimize patient benefits of prescription drugs dispensed, the primary obligation must be to fill the prescription correctly. The promise is perhaps best stated as “First, do no harm.”
Continuous Quality Improvement
Almost every pharmacy, whether hospital or community, today has introduced a continuous quality improvement plan into its pharmacy practice workflow. In order for these tools to be effective, we must make sure the CQI program in place is used faithfully and completely.
This means that during busy times when the prescriptions are stacked up and nurses and patients are waiting, pharmacists and pharmacy technicians will resist the temptation to speed up the process by skipping steps. We ensure this by training and instilling quality habits as part of the workflow.
We also do it by auditing. Auditing is quality control. No CQI system is complete without monitoring for quality. One form of quality control is checking each prescription several time during the filling process to stop “near misses” from becoming errors that reach a patient. It also includes a vigorous system of reporting of error incidents followed by appropriate root-cause analysis. A root-cause analysis allows the pharmacy staff to correct the mistakes that led to the error, which should reduce the risk of this error happening again.
It is not enough, however, to study errors that reach a patient. It is equally — perhaps more —important that we monitor our system to discover all mistakes that enter into the workflow that could, if not caught, reach the patient and result in an error and possible injury to a patient.
In most pharmacies with a CQI system, more than 10 mistakes occur for each error that reaches a patient. The most effective way of eliminating errors is to reduce the mistakes that can lead to the errors. Without mistakes there are no errors.