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.  

High Risk Medications and Emergency Room Visits


                High risk medications are associated with emergency department visits and hospitalizations due to either adverse events or medication error.    The medication classes listed below are considered “high risk” because they require extra monitoring and are associated with a higher rate of adverse events. High risk medications are most often prescribed for high risk populations. 

                A two year study evaluated the frequency of emergency department visits and hospitalizations across a representative sample of 63 hospitals using the National Electronic Surveillance System-All Injury Program (NEISS-AIP).  The study design allowed the results to be applied to the entireUSpopulation.  Based on the study estimates, approximately 700,000 patients are admitted annually to Emergency Departments due to adverse events associated with high risk medications.  Almost 100,000 patients are admitted to hospitals due to high risk medications. 

              Patients younger than 5 years and those older than 65 years are most often involved with Emergency Room visits related to high risk medications.  The medications most often associated with hospitalizations include:

*Anticoagulants  (Coumadin– warfarin)

*Insulins including rapid, intermediate and long acting varieties

*Opioid-containing analgesics (morphine, methadone, fentanyl)


*Oral hypoglycemic agents (glyburide, glipizide)

*Antineoplastic agents (methotrexate, mercaptopurine, cyclophosphamide)

                 If any of these high alert medications are involved in medication errors the implications can be serious.  If the wrong patient receives another person’s high risk medication through a point-of-sale error, this could result in hospitalization.  For example, a non-diabetic receiving another person’s oral hypoglycemic agent can result in dangerously low blood sugars (a severe hypoglycemic reaction). 

                Pharmacy best practice when dealing with high alert medications includes reading the prescription carefully while entering prescription information, making sure that you select the correct medication and ascertaining that all system alerts are reviewed carefully.  Remember all medications can be dangerous and are only safe when administered to the correct patient.  Keep in mind that we are all human and capable of making a medication error.  Raise your safety awareness and pay even closer attention to detail when working with high alert medications. 


Budnitz DS, Pollock DA, Weidenbach KN, Mendelsohn AB, Schroeder TJ, Annest JL.  National surveillance of emergency department visits for outpatient adverse drug events.  JAMA 2006;296(15):1858-66.


What is Just culture?

“We can’t change the human condition, but we can change the conditions under which humans act.” James Reason¹

What is Just culture

Safety awareness is on the increase at healthcare organizations across the country.  Along with this awareness is an important opportunity to report both medical and medication errors.  Increased reporting allows healthcare organizations as well as Patient Safety Organizations to better understand systems and human actions that contribute to error.   The biggest factor preventing the reporting of medication error is fear; particularly the fear of losing professional licensure, reputation and employment status. 

In order to overcome this fear, an organization must shift from a widely held cultural practice of shame-and-blame to a non-punitive Just culture.  This new culture acknowledges that human and system errors exist alongside each other.  Just culture recognizes that even the most experienced, competent and caring healthcare workers are not exempt from human error.  The modern patient safety movement has taken a ‘system focus’ requiring safety researchers to better understand the role systems, workflow, workload, workplace environment and process play as causes or contributing  factors of error.  Just Culture strongly encourages reporting of medication error where health workers are never punished for reporting.   

While the blameless / non-punitive aspects of Just Culture have been addressed, it is important to note that the developer of Just Culture (David Marx) acknowledges the need for accountability within a culture.  Marx distinguishes three distinct behaviors within a Just Culture as follows:






Human Error

Safety Actions are consistent

Safety ‘work-around’ behavior is uncommon

Staff follows all Safety  Policies and Procedures


Learning environment

Incident / errors reported regularly

Management encourages Safety Behaviors and error reporting

“At Risk”

Safety Actions vary based upon work conditions

Safety ‘work-around’ behavior is common.

Adherence to Safety Policies and Procedures  is inconsistent

Creates unsafe conditions.  

Behavior may be viewed as acceptable or unacceptable depending upon local safety culture and attitudes.

Incident / error reports sporadic


Conscious violation of safety system

Decision Support System alerts disregarded

Non-Adherence to Safety Policies and Procedures 

No regard for patient safety and welfare

Behavior seen by coworkers and management as unacceptable and dangerous with serious consequences

Attempt to hide errors

Incident / errors go unreported


Safety Awareness begins with you and your work team every day!  Recognize that medication errors can happen to even the most experienced healthcare workers.  If your Safety Actions are consistent and you follow all Safety Policy, Procedures and Processes, there is significant opportunity to reduce medical and medication error and prevent patient harm.  Consider reporting error without fear of punishment. This will help the entire organization learn.  Why not create a Just Culture starting today?


1.       Reason J.  Human error: models and management.  BMJ 2000; 320:768-70. 


Why not The PSO Advisory?

It is interesting to review the definition of something, for in defining it, we begin to act.  Once we define, in addition to the descriptive meaning, we add intention, i.e. we stipulate.  It becomes our guide.

Safety frees us from the occurrence of risk or injury.  In defining safety, we add a behavioral component…we stipulate.

Collection of data and its analysis thereof starts us on the safe path with an inherent appropriate intention…to change culture and behavior.

Why not enlist a Patient Safety organization to start you on the road to those changes?

And why not The PSO Advisory?

Why a Patient Safety Organization?

There has been a delay in the patient safety march.  Why so?  Because we have yet to overcome the knowledge gap in how to get it done.  We have to be better at answering the question, “Why a Patient Safety Organization?”

The number of adverse events, death included, has changed little since the Institute of Medicine report of 10 years ago…100,000 deaths at a cost of $30B per year.

With databases full of quality/safety information and its analysis thereof, we should be able to make a difference.

We can gather the data.

We can analyze it.

We can make a difference.

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