Individual and Collective Safety Mindfulness – It’s all about the patient

                  Is the patient safe?  This is one of the most important questions a healthcare worker can ask themselves.  In pharmacy practice, keeping the patient safe means ensuring every system is in place to assure the patient receives the correct medication.  In today’s patient safety culture, “correct medication” usually means whatever medication was on the prescription.  However, “correct medication” can also mean the appropriate therapy for a patient, at the correct dose, taken at correct intervals, which will not interact with a patient’s other medications.  To keep the patient safe, all parties involved have to be mindful of anything that could impede dispensing the correct medication, whatever the definition of this term may be.  This mindfulness, of the organization and individuals involved in a patient’s care, is termed individual and collective mindfulness.

                  A collectively mindful organization understands humans and systems can fail.  These organizations put safeguards and constraints in place in their systems to decrease the likelihood of human error.  Collectively mindful organizations are cognizant of the fact errors will occur and “unpleasant surprises” will slip through but they are equipped with the personnel and tools to evaluate system failures and find value in the data for further improvement.  Collective mindfulness allows organizations to move forward and improve themselves while always keeping the basic principle of healthcare in mind; to provide safe and high quality care to the patient.

                  System safeguards and system constraints designed to influence human mistakes that lead to medication errors may have limits on their effectiveness.   Individual mindfulness is the other half to patient safety.  Individual mindfulness is defined as insight into the current state of the individual (self-awareness) to the environment in which one works, and the level of skill required to safely accomplish the task at hand in order to make the right decision for the patient.  The mindful pharmacist or technician is conscious and aware of his or her fatigue, inexperience, health, lack of knowledge as well as the distractions, interruptions, or lack of time which may all get in the way of completing a task in a safe manner.  The mindful individual is therefore able to detect what is termed ‘unsafe conditions’. 

                  Individual and collective mindfulness work together in preventing errors from occurring and improve patient safety.  An individual’s as well as the organization’s awareness of their limitations are imperative to better understand how errors occur and how best to prevent reoccurrence.  Individual mindfulness can prevent errors from occurring and collective mindfulness identifies areas of system weakness (latent system errors) where errors can or will occur.  Both of these mind sets converge into one basic goal: ensuring patient safety.  

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