Interview with Sally Rafie, Assistant Professor and Pharmacist Specialist in Medication Safety at UC San Diego Health.
"Pharmacists are the medication experts and can often manage medications more effectively than other provider types. Each health care professional has a niche within the patient care team and this needs to be recognized by insurance companies, including the government."
For years, hospital pharmacies loaded patient medications on to carts that were then delivered to hospital wards to be distributed by nursing care staff. But since the late 1980s, hospitals have turned to automated prescription drug dispensation for a safer way to deliver needed medications to patients, which has provided healthcare facilities with a more decentralized medication distribution system[i]. For pharmacist specialist Sally Rafie, identifying system weaknesses in medication distribution safety has been her life’s work, something she first became interested in as a pharmacy resident at UC San Diego Health General Hospital.
Rafie’s interest in medication safety began with a study of the pharmaceutical industry’s health policy and management issues in her final year of pharmacy school. The coursework helped her better understand the FDA’s role in protecting consumer safety as well as the pharmacist’s role in patient safety. Before that, she earned a bachelor’s degree in biochemistry and molecular biology from the University of California Irvine. She then earned her pharmacy doctorate degree from the University of California San Francisco. As a board-certified pharmacotherapy specialist, Rafie is considered an advanced expert in the field of pharmacy, with a specialization and deep interest in medication safety and women’s health issues.
Rafie has been published in a number of peer-reviewed medical and pharmacy journals, such as Contraception, Pharmacotherapy, Obstetrics & Gynecology, Progress in Transplantation, the Journal of the American Pharmacists Association, the American Journal of Health-System Pharmacy, Pharmacy Education, the Pharmacy International Journal of Women’s Health and many more. She is also a regular speaker at conferences, including the American College of Clinical Pharmacy, West Coast Pharmacy Exchange, and Emergency Contraception Jamboree annual meetings.
Enjoy our interview with Sally Rafie about her career and experience in medication safety and how she advocates for changes and improvements to safety protocol across the country.
How did you first become involved in medication safety, and why did this area interest you?
I had a bit of exposure to medication safety on an elective rotation in pharmacy administration at San Francisco General Hospital. My interest really peaked during residency. I didn’t even realize it at the time, but I had a knack for identifying system weaknesses and would take on projects to improve upon those systems.
For example, when rounding with the abdominal transplant team, I found that we could do more to screen patients for pregnancy priorto surgery and educate patients about effectively preventing pregnancy after surgery. Transplant recipients should not become pregnant immediately after surgery since it can have bad outcomes on their organ, as well as expose the fetus to medications that can cause birth defects.
In another instance, I became aware of the potential for medication errors with birth control pills. These pills are used in the hospital to treat abnormal uterine bleeding. I investigated the issue further and found that we had a long list of different pill formulations on our hospital formulary. One strategy to reduce medication errors, is to standardize medications on the hospital formulary and available in the inventory. With the help of a pharmacy student, I was able to determine how we were using these medications and which formulations would be most appropriate to keep. The process for using these medications was then redesigned to decrease the risk of errors. This project was published in the American Journal of Health-System Pharmacy so other hospitals could proactively evaluate their risks and potentially adopt our approach as well.
Tell us more about your educational background, and how did that help to prepare you for your area of specialization?
My pharmacy school gave us the ability to pick one of three tracks for our final year. Whereas most students chose the clinical path, a minority of students (myself included) selected the health policy and management or pharmaceutical sciences tracks. I chosethat track due to my interest in influencing practice on a larger scale. During these special courses, I learned more about the FDA’s role in protecting consumer safety and the pharmacist’s role as well.
Can you describe your role and your typical duties involving medication safety and patient safety?
My days are comprised of committee meetings, event investigations, preparing education materials, evaluating practices, and conducting audits. As the only point person for medication safety for a large academic health system, I have a big responsibility. The medication safety pharmacist serves as a leader within the organization to influence practices that ensure safe use of medications and mitigate patient harm from adverse drug events.
I am also involved in general patient safety efforts within my organization. I am a member of the Patient Safety Committee and have been involved in patient safety initiatives not related to medications, such as breast milk administration to infants. In my current role, I coordinate medication safety activities across the organization, from our hospitals, to our cancer center, to our outpatient clinics and outpatient pharmacies.
What are the biggest challenges/problems you encounter in your profession?
The biggest challenge I have faced is the lack of reimbursement for pharmacist services. This lack of reimbursement has prohibited me from providing direct patient care services to the extent that I can. There are some legislative changes being made to address this, but the disparity still exists. Insurance companies will pay a physician, nurse practitioner, or physician assistant for patient care services but will not pay a pharmacist for the same service. Pharmacists are the medication experts and can often manage medications more effectively than other provider types. Each healthcare professional has a niche within the patient care team and this needs to be recognized by insurance companies, including the government.
What changes and improvements in medication safety practices have you seen in recent years?
Technology has had an enormous impact on medication safety practices. The ability to leverage technology to increase efficiency and accuracy of healthcare delivery has been revolutionary. We now have technology that has changed medical records, drug dispensing, drug administration, and monitoring.
There has also been a major shift in culture as it relates to patient safety. Decades ago, healthcare workers were punished for making medication errors. Now, we emphasize a Just Culture that is primarily focused on building a robust system for healthcare workers to function in, with an additional accountability for healthcare workers to make good decisions within that system. This has major implications for improving medication safety. As you can imagine, people are less likely to report and share their errors if theyfear retaliation. And if we don’t know what errors are happening, we can’t change the system to prevent those errors or learn from them. Safety is a hot topic that many front-line healthcare workers, including physicians, are now aware of.
What are the benefits of using automated drug dispensing systems?
Automated drug dispensing systems have many benefits including timeliness, accuracy, and efficiency of drug dispensing. In addition, effective use of these systems mitigates medication errors by limiting access to medications other than the intended medication,as well as to medications that have not yet been reviewed by the pharmacist. Further, these systems capture activity such as which user removed which medication from the system.
What specific healthcare safety issues do automated drug dispensaries address?
Automated drug dispensaries (ADDs) primarily address potential sources of error and delays in dispensing medications. They can improve efficiency by eliminating delays for delivering medications from the pharmacy to the patient care unit. ADDs replace medication cabinets where medications were stored before this technology was available. In the old cabinets, we relied on paper logs to track inventory and relied solely on the healthcare professional – usually a nurse – to select the correct medication from the cabinet. However, there can be errors with this because all the medications are available and not always well segregated. The human eye can miss subtle differences in a medication name or concentration. On the other hand, ADDs allow us to only make the correct medication available. So other medications can remain locked in separate spaces in the matrix. If we cannot access the wrong medication, we cannot pull that wrong medication and give it to the patient.
What are the drawbacks or limitations of these automated systems?
There are some drawbacks to these systems. For staff who are loading medications into the drawers and staff who are removing medications, there are some ergonomic challenges. Some of the drawers are mere inches from the ground and staff must bend down to reach these. Some of the drawers may be above reach and users must pull a heavy bin full of medications to reach the one they need. Some of the touch screens are not as accurate as they should be and we’ve seen a lot of medications pulled under the wrong patient name.
What developments to drug dispensing technology would you still like to see in coming years?
Some of the developments that are being made include color screens, allowing nurses the ability to queue up the medications they’d like to remove from any computer using the electronic medical record (EMR), and dispensing the exact quantity of medications – as opposed to the pocket opening and the user removing the quantity needed.
I’d like to see even more communication between the ADD and EMR. Imagine if the ADD would not dispense medications until the last set of medications dispensed have been charted as administered in the EMR or wasted. This would prevent mix-ups between medications intended for different patients. It would also be more efficient and safer if the ADD and EMR used the same barcode databases for medications. So a new medication that is stocked by the hospital can be added to a single database for scanning, rather than two different databases.
What do you see as the future of healthcare, and how do automated drug dispensaries fit into that picture?
I see ADDs as part of the healthcare picture for many years to come. This technology allows us to store and dispense medications inan accurate and timely fashion at the point of patient care. ADDs will continue to allow pharmacy technicians to load these machines in bulk and spend their time preparing patient-specific IV and other medications, in addition to other functions such as checking emergency medication supplies. In turn, this allows pharmacists to spend time on clinical activities that improve patient outcomes.
Do you have any advice for students interested in pursuing a pharmacy technician degree? How can they prepare themselves for the challenges of the industry?
Pharmacy technicians are vital to the operations of medication use in health care settings. They are able to impact patient carein a very positive way, especially in the community setting where they interact with patients for prescription processing as well as in hospital settings where they conduct patient medication histories. Pharmacy technician roles are expanding. Students can prepare themselves for change and innovation early in their training. Take advantage of training opportunities to maximize versatility in the workplace.
Finally, we want pharmacy technicians to feel empowered to contribute to performance improvement. If you see a weakness in the procedures or systems being used, speak up! We rely on feedback to improve systems and ultimately make it easier for you to do your job. Nobody wants to make a medication error and you will have great ideas on how to prevent errors.
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