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Thanks for joining us in the episode of Practice Journeys, the podcast where members share their stories about their professional path, lessons learned, and how their experiences shaped who and where they are today. My name is Savannah Scott, and I'm going to be your host. I am currently an emergency medicine pharmacist at Riverside Regional Medical Center, and today we will be chatting with three panel members about handling medication errors as a new practitioner and its importance in career development. Thanks for joining us today, and I will let each panel member introduce themselves and tell us about their current role. Hi, Savannah. I'm Callie Kane. I'm the medication safety and regulatory compliance program manager at Riverside Health System in Virginia. Hey, Savannah. My name is Jason McNulty. I am a medication safety officer at Parkland Hill. Hey, Savannah. My name is Morgan King, and I am a women's and children's clinical pharmacy specialist at Cleveland Clinic Fairview Hospital. Thank you all for joining. We're really happy to have you here. Let's dive into our first scenario. So our first question today is to describe your first mistake as a new practitioner and how were you able to grow and learn from this mistake. So prior to our panel's response, I wanted to share what inspired this podcast session. Specifically in healthcare, we work in an environment where we are expected to be perfect, but that is impossible by definition. When mistakes are inevitably made, it leads to emotional and psychological stress. And we make question, how could I let this happen? How could I make a mistake? But that's enough for me, and I'd like to kick it off our first scenario with Kelly Kane. Thanks, Savannah. And that's 100% right. I think everybody goes into healthcare, hopefully, because they want to help people. So it can be really devastating, especially as a new practitioner, when you have to face the back that you're a human, and that humans make mistakes. So I can share my first memorable mistake. I'm sure I made some other mistakes before this one, but my first really memorable mistake was when I was working as an emergency department pharmacist. And I was primarily responsible for orchestrating a med rack team. And as a patient came in, I was reviewing their prior to admission medication list. And this patient was coming in from a skilled nursing facility, and they had been on bacamise and prior to admission. So the patient came in with acute kidney injury and some signs and symptoms of sepsis. And as I was reviewing that home medication list, I noticed that I couldn't find any levels for the patient. And so I went and talked to the emergency department physician, and I recommended that they draw a level just because the patient was on bacamise and did have the acute kidney injury. And I feel like in many of these stories, you'll hear it was like close to the end of your shift. Everything always seems to happen close to the end of your shift. So I did that handoff and I went home for the day. And then when I came back the next day, I followed up on my patient and saw that their bank level had come back at greater than 100 mics per ml. And before that level returned, they had received an additional dose of bacamise. And so in hand off, it appears that my communication did not reach it to the next physician that was taking care of that patient. And at that time, we didn't really have a system in place to do a robust check on prior to admission meds before verifying orders coming through, especially for a septic patient, where they might be worried about the timeframe. So that was the first one. And I was, you know, as soon as I did, I was kind of like asking myself all of the things that I could have done differently to help that go better and make sure that it was handed off in a different way. I had made a note, but it was just on the home medication list and epic. And we didn't, as I mentioned before, we didn't really have all the checks in place to make sure that that piece of information made it to that next physician and then to the pharmacist who was verifying that order. Thank you for sharing. And now describe the first steps you took after making this mistake. Yeah, after I made that mistake, I filed an event report because I wanted to just, I think at that point, just being so new, I was named in my hospital. I was really new to pharmacy. And I kind of thought of it as like self-reporting and opinionative way, almost like I wanted to, you know, confess that, you know, I hadn't done the parts that I wish I had done for this patient. And then fortunately, you know, that's not, they were, I was in a just culture situation. So it turned out to be a good thing, I think, even though that's not initially like how I, I kind of seen it. Yeah, for sure. So this took me back when I was going through the questions for this podcast about, you know, my first mistake as a new practitioner. And that's my exact response as well. I immediately called my clinical manager and self-reported the event. And I had similar feelings as well. And yes, and luckily we work in an environment with just culture. I'm so it's just interesting how as new practitioners, we have similar responses to the same question. Our next question for this topic, are there any process improvement initiatives at your practice site after this event? For that event, I think, you know, the main opportunity that I saw, and when I discussed this with the clinical manager for infectious disease, she was the one who was working on the event report, I saw it as an opportunity for better hand off to the pharmacy team. So in the ED, things can feel a little bit isolated. And you sometimes forget that you have a whole team of people in the pharmacy who have your back as long as you remember to engage them. So that was a really important lesson learned as a newer emergency department pharmacist that set me up for success and, you know, really working through that additional layer of safety when I had medication aids in the emergency room. And lastly, relating to this scenario, so if you could go back in time, what would you tell your previous self during this scenario? And any specific advice for new practitioners who may find themselves in a specific situation? I would tell myself that medication safety is a team sport. So I just remember when I realized that they had gotten another dose before they had gotten the level result, I kind of saw it as a personal failure. But now that I'm working in med safety, it's a lot easier to look more objectively at it and notice all the holes in the Swiss cheese that align for that to happen for that particular patient. And I think, you know, having that insight has really helped. I think working as a clinical pharmacist has helped me understand and appreciate how hard it is to practice pharmacy anywhere and especially in an emergency room when you never know what's going to happen from day to day. So having some self compassion around it and understanding that mistakes are there for us to, their teachers, for us to learn things and to grow and to be more vigilant next time in a similar scenario. Thank you so much for sharing. I do appreciate that. I was lucky when I was a new practitioner. I guess I still am when I made my first medication error. Kelly, we work in the same institution, so she was able to share all of this feedback with me in real time and be supportive. So I hope everyone else can also become best friends with their medication safety officers. Thank you. All right. We're going to take it back to the top with question one again with JC. So describe your first mistake as a new practitioner and how were you able to grow and learn from this mistake. I think in the sense of kind of what Kelly was saying, I'm sure that I've made others, but kind of for the most memorable one in thinking about when I actually became a resident. This happened during my first year of residency. And so it was my first staffing weekend that I was staffing alone for that team. So I've had training for weekends previous, but this was kind of the first weekend that I was the main pharmacist in charge. And so kind of all of the nerves were there. And so I was like, hoping I don't miss anything, hoping I don't kind of make any mistakes that kind of pressure was already there during that weekend. And so I remember that there was, and I'm not sure for those who are listening in for you as well, if you're familiar with Epic, I'm not sure what your institutions use, but we are Epic institution. And so there was a patient who needed a medication, believe it was hydrolyzing, and the nurse sent a more message asking if they could get another dose. And so this medication was in our PICSIS machine already, but because our PICS machine had ran out of that mid and it hasn't been reloaded. At that point, they were seeing if they could get another one from pharmacy. And so kind of me being in a rush and I remember being kind of in a rush, when I hit and hit retispence and thought the medication was coming from pharmacy sent a message back to the nurse, it should be there shortly. You can look at for it at our tube station. And so it maybe it was about 20 minutes or so later, it's in another message and asking for that same medication. And I was thinking, okay, well, maybe pharmacy's a little delayed. Let me go ahead and maybe send another Bredispence. And then it wasn't until that third message that she has to like, hey, I'm still missing this medication. Can you send it for pharmacy that I realized I was retispensing back to the PICSIS machine, not from our actual central pharmacy? And so I mean, it was like, okay, well, now understand why it's, you know, taking you a couple of times to respond back to me or kind of continue to ask what was going on, because I wasn't truly dispensing the medication from the right location. And so, you know, went ahead and did that correctly send a message back. And I know over the course of the time from when you first message with a couple of messages that happened from when the medication finally reached it to the nurse for her to administer it, I know it had been at least a couple of hours. And so went ahead, I didn't necessarily think too much of it more in the fact of, okay, Jason, now it's kind of rethinking, hey, how many times had it done that previously? Let me make sure I'm being, you know, paying more attention and paying a little bit closer attention when I'm doing that moving forward. But definitely kind of stuck with me a little bit. And I was like, okay, how just yeah, it kind of stuck with me and just wondering how many times I had done that prior to that situation. So in thinking about kind of the second part, like, what was I able to learn from it, I know I made a mental note, like, hey, when this happens, when you get messages, I know for that day, specifically that I was deaf and everyone I looked at, I think I double and triple checked the location that I was dispensing those meds from, because I wanted to make sure I wasn't potentially causing any other delays. Yes, thank you for sharing. I think we can all relate to our first staffing weekend, whether you were a resident or not a resident. So on to the second part of the question, do you remember your very first step that you took after making this mistake? And were there any process improvement initiatives at your practice site? I'm not sure if it's as applicable for your question. Yeah, Art, I think going back to like the first steps, I think once I realized what happened, my first like next steps were the rest of the day, making sure I was kind of doing those double checks from the messages. But this was something that from the nursing standpoint, because it was more of a delay from there being able to administer that men and give that to the patient. This was actually reported in our safety center. And so the next the following Monday, when I went back, our kind of covering manager followed up with me about it. And so that brought us so they're kind of nerves along and kind of anxiety, because I was the first first weekend for staffing, but also first time that I'd been on the other end of an errand kind of being the one that contributed to that delay. So from that standpoint, I would say the follow up and kind of next steps was being involved there. I think that early kind of helped me be a little bit more conscious and think about those things as I progressed through residency, progressed through staffing, because I in a way, I think it also kind of took the edge off of thinking, okay, this happened, you know the process, you know what the follow up is. Be mindful, continue to pay attention to detail when you're moving forward, but also knowing that these, you know, it's more than just me affecting this patient, it's nursing, it's everyone else. And so thinking of that, that kind of was the next steps and just kind of being more conscious during my practice. But in terms of process improvements, our team was already implementing kind of dispense tracking prep and check within Epic. So that wasn't necessarily a significant change that happened afterwards, but over the course of that until now, we have been trying to make more strikes and being consistent with those dispense prep check and tracking for all of our medications. And so in thinking back, had I been, you know, conscious and looking at that, I could have known probably after that first dispense. Hey, I see this hasn't been prepared or worked on for a little bit. Let me see what's going on. So just being a little bit of conscious of that probably would have felt me identify sooner. Definitely. Thank you so much. Also, especially when you kind of had that feedback from your manager, you know, especially when you're a new practitioner, the first thoughts that go through my head sometimes are, you know, I'm in trouble, things of that nature, I'm sure, you know, sometimes there's a lot of tears during those conversations. If you could go back to that moment, is there any advice that you could share with other new practitioners? Yeah, I think I remember when I first got the email, I think my heart dropped because I don't even know if I truly read the whole thing. I just kind of started the top and as soon as I realized what it was about, I think I just kind of based out a little bit. But I will say, like we're talking about the kind of what the theme of this podcast is, it's, you know, medication errors are going to happen. I mean, human errors are going to happen. And I think understanding and kind of learning from them moving forward is a good goal in that kind of being paralyzed by, you know, like, I don't want to make an error. I don't want to make any mistakes and kind of letting that paralyze your practice. I think we all know Kelly said this earlier, we come to work every day to help our patients. No one's coming intentionally trying to harm anyone. So knowing that the errors that we make to be learning lessons could help us identify better ways to do things, better processes that we can take. But knowing that if you are involved in the air and kind of thinking about my previous self, reading that email and knowing that that happened, continuing to practice and continue to use that as a learning lesson and not letting that paralyze you, which probably would be the thing that I would share with myself and share with others who are involved in events. Thank you for sharing. Yes, I definitely echo that. That's amazing advice for our new practitioners. All right, now we have Morgan back to the top with describe your first mistake as a new practitioner. And how were you able to grow and learn from this mistake? Yeah, so similarly to Kelly and JC, I will say this isn't necessarily my first mistake, probably about one that I remember. So in my current role, I do a lot more clinical work, so I don't do a whole lot of operational work. There's some like I do some order verification, but not as often as some of our other pharmacists. And so I remember we had a baby who was in our NICU, who was actively seething, we had loaded with, you know, barbered all that morning. And the resident, we were going to start maintenance, you know, barbered all per neuro recommendations. And so I guess kind of as a little bit of a background with babies and dosing. So we use their birth weight when we dose medications and most babies will lose weight initially because they're balls of water. And so the resident had been having a hard time entering orders for this baby. He kept using that day's weight instead of the birth weight. So just had to be very vigilant in checking what the orders were. And so when he entered the maintenance dosing, he used the wrong weight. And so I went in to fix it and was in such a mentality of making sure the dosing weight was correct and that the dose was correct, that I did not pay attention to the timing of the medication. And so normally you would start the maintenance dose 12 hours after the loading dose. And I had entered it to start at that time. And so luckily we have really great nurses. And so the medication was compounded and dispensed from main pharmacy and sent to the NICU. And the nurse realized that, hey, we just gave the loading dose like I can't give this right now. So it never actually reached the patient, but it was an error that I had made that could have reached the patient had the nurse not been vigilant. Yes, thank you for sharing, especially being a pediatric pharmacist, just taking care of one of the most vulnerable populations. I really appreciate your perspective as well. So going back to your scenario, do you remember the first steps you took after making this mistake? Yeah, so I remember the nurse called me and mentioned it to me and thinking like, oh my gosh, how did I miss that? And so I went back in and looked at it and helped fix the order so that it was timed appropriately, made sure it was reentered. And now I would say, you know, any time that I'm doing order verification, that is always something that I am mentally thinking of, it's okay, did we get a dose of this already? That was maybe like a one time order for any of my patients, not even just in the NICU, you know, looking at their more and making sure that everything checks out so that we're not giving duplicate doses. And if you could go back in time, what advice would you give to yourself or other advice for new practitioners with handling their first mistake? Yeah, so I think I don't know of any pharmacist who is not a type A OCD perfectionist, including myself. And so I think just reminding people that we're not perfect. And like we've already mentioned, like none of us are coming to work with the intention to harm anyone, you know, we're here to help people, but we're not perfect and mistakes are likely going to happen. And so knowing that they're going to happen and just having that awareness and that, you know, when it does happen, trying to use it as a learning point and a growing point is going to be really important in your career. Great. Thank you so much for going through those scenarios. I'm going to move on to our next question. Have any of the panel members identified any self-help resources that you found helpful in coping with grief or were you able to give these resources to others in your pharmacy and maybe they have found it helpful? And I can take that one. This is Kelly. So in terms of resources that help with grief, last year at the ASHP summer meeting, they had a great presentation on stress first aid for health care workers. It's a resource, the National Center for PTSD. And it really gives us a framework to help health care systems support their team members in dealing with making mistakes. So obviously with veterans, they're well versed in having to deal with PTSD, but applying that even more broadly to people who take care of veterans and then even the greater health care community. I found that to be an exceptional resource and was actually able to share that back with my own health care system. And then in terms of kind of like a softer resource, something that I've really connected with recently is some of the work by Pama Chodron. She has a book called Welcoming the Unwelcome, which really talks about seeing things that seem bad as essential to growth along your life journey. So between those two resources, I found them to be very helpful in terms of generating self-compassion and using mistakes as kind of a framework to grow in life. Yes, thank you for sharing that. I'm definitely gonna steal those and put them in my back pocket. Does anyone else have any other resources they would like to share? This is J.C. I guess I can kind of piggyback off of what Kelly said. I think from an institution standpoint, having resources to help support employees, I think are really important. And so I know that our institution has an employee resource groups as well. They have employee help groups for all types of resources. It's financial, if it's grief, if it's anxiety, anything that employees need, there is a group specifically for that. So I think that that's important. And I think it's been helpful and usually for our employees who are involved in events, that's something that we'll kind of point them into the direction so they can at least get that help here while they're at their job. And so also kind of on the self side and kind of more personal, I know that I like those like motivational apps and kind of reminders on your phone as well as I know with your watch shows. We have like Apple watches, I like having a breathe or the, you know, taking a second to kind of decompress and just kind of relax yourself. I think that that helps. I don't know about everybody else, but for grief and anxiety, for me, I know we'll kind of come hand in hand. So if it's ever moment that I'm also getting too anxious or getting too worked out, I mean, a work day can be long if you're anxious and feeling kind of grief throughout the whole process. And so being able to kind of take a second to step away, if it's not taking a walk. I know we have 17 floors in our hospital, I know some like to go and walk up the stairs to kind of just get their mind and separate things for a little bit. So taking that time, if it's not just to get a little mobile, they can factor 10 minutes to take a break from what you're doing, make help you be able to get through the rest of the work day. Thank you. That's great advice and resources. I have two found myself after a difficult patient case in the ED. If it's a nice day going outside, taking a loop around the hospital. So those are all very important. Morgan, did you have any resources you would like to share with the group? Yeah. So I mean, I would echo that most institutions have some sort of counselor or person that you can go to. But I think it's also important to remember that you can lean on your team. Most of us work in health care teams, right? Like it's not just only your pharmacy team, which is still team, but like if you're with a medical team, physicians, nurses, social work, whoever. So leaning into them because depending on what the error is, they're probably also going through that same type of grief and anxiety feeling. So just being able to talk to them to kind of decompress after really bad situations, even utilizing your support system at home, whether that's a spouse, parent, sibling is also a really great resource that I like to use. I know my husband is also a pharmacist. So being able to generically talk about errors that have been made or really terrible patient situations that have happened, it's nice to have that other person there. Thank you for sharing all these amazing resources. Our last question of the day is to describe any challenges in emergency situations, especially potentially with verbal orders or mitigating medication errors that may potentially sway away from the ASHP guidelines on preventing medication errors in hospitals. I think one of the things that you really have to grapple with when you stop to roll in medication safety or even just to roll in health care is the ideal framework that's often painted in guidelines and resources. And then the real world version of what life actually looks like, what life looks like with certain resources, et cetera. So I think a lot of the guidelines that are published are great gold standard advice for how to build robust processes and systems that prevent errors from reaching patients. And that's where we want to land. In reality, the solution that's going to help today or tomorrow even is the one that's going to work for your team. So I think that that's a really important thing to keep in the back of your mind when thinking about how to improve systems and processes in a way that will close those gaps in the Swiss cheese model. And then my personal strategy for this is to definitely keep a pulse on front line. Like, what does their life look like? If they had a mistake, talk with them, talk, what do you think would work maybe to prevent this from happening again? Because that's where you're going to get your tomorrow solutions generated from. And then you can even work with them on, you know, if we're going to test one of these, which one would you test first so that you're able to work together. And then often you have that engagement that you need to really try it out fully. And then you can track behind it and make sure, first of all, that it's fully implemented. And then that's your, it's actually achieving what you want it to achieve. So if you're able to get that happening across an entire health care system, you're able to make kind of like this incremental progress. But it's not going to look exactly like you see in the guideline or in the best practice literature, because that's going to take time for it to get where it needs to be. Thank you. I think that is great advice, especially being a new practitioner and the emergency department setting. You, you know, learn all of, like you said, these guidelines and standardized rules. But when you're put in that situation of you're only getting a verbal word or you need to get a medication prepared very quickly, sometimes I found it challenging as a new practitioner on how to handle and kind of like mitigate strategies on keeping our patient safe. All right, JC, did you have anything else to add for describing any challenges and emergency situations for our new practitioners? Yeah, I mean, I could echo a lot of what Kelly, that I do think of kind of like you say, like the standards guidelines, they are great and we all like to rely on those. But, you know, oftentimes health care, practicing medicine is not as black and white as we would all like it to be. So operating in the gray definitely comes a lot more often than we would probably like to say we see. So I would say kind of an emergency situation, especially when you're thinking about like verbal orders and how you can mitigate those errors. I know for our institution, we've talked a lot about kind of our journey with being a highly reliable organization and thinking about some universal skills that you can use and thinking about with verbal orders. And if you get an order and it's a high intent situation, it's really easy to, you know, be in a high pressure situation and, you know, miss hear something or not understand what the order was or, you know, possibly pull the incorrect medication, give the correct medication or the incorrect dose. And so making sure you're kind of confirming what you're hearing using those skills of repeating back what somebody has told you, getting cross checks in the process. And so even though it's an emergency situation, taking a second to kind of confirm what's going on and confirm what somebody else to make sure that multiple people on the same page can help even in those emergencies, taking that one or two seconds to kind of stop and recheck things, I think can help with some of those medication errors that especially lead to possibly given the wrong medication or pulling something different than what was intended. Yes, and I just want to echo that. I thought it was interesting when I was reading and preparing for this podcast, the ASHP guidelines on preventing medication errors in hospitals. They had a scenario specifically for the verbal orders with if you get a dose for 15 milligrams to echo that back the verbal order, as you said, it's one five. And I don't know why I had never really thought about repeating a verbal order back in that way. So I just thought it was interesting in a good potentially mitigation strategy. Well, right, Morgan, any other comments about any challenges with emergency or high stress situations? Yeah, so I think one of the biggest challenges that I face specifically in the pediatric world is that a lot of medications come in concentrations that are not measurable for some of our smallest patients. So again, referring to the NICU, but even some of our pediatric patients. So you have to find the dosage form that work or a lot of the times in emergency situations, it comes down to really doing bedside dilution of things. And you know, we try to mitigate that by printing emergency med sheets for every patient when they come in, because we do weight based dosing. So we figure out what is their weight and what would their dose be of these emergency drugs? Should we need them? And we try to have that printed at bed side. So that way, we know like, okay, this is going to need diluted, or this is the volume you're going to draw up of this certain medication. So that way it can be done in a quick family manner emergent situation. But you know, I think it's also important to echo like what J.C. said taking that extra second or two just to double check like, did I draw the correct dose? Did I dilute it? Should I have diluted it if I didn't? You know, if you have somebody else there who can double check your math and put a second set of eyes on it, that's always nice. And you know, you try to like prepare for what you think the physician's going to need. So you can do all of this ahead of time. But in an emergency situation, you never know what's going to happen. So all right, well, that's all the time we have today. A big thank you to Morgan, Kelly, and J.C. for joining us today to discuss handling mistakes as a new practitioner. If you haven't before, I encourage you all to check out ASHP's new practitioner resources. You can find member exclusive offerings such as targeted materials on career transitions for new practitioners, career development resources, and research tools. Be sure to also check out the new practitioner's connect community where you can exchange ideas with your colleagues. Thanks again for tuning in for this session of practice journeys. We hope you've enjoyed today's conversation and be sure to subscribe to ASHP podcast through your favorite podcast provider. Thank you for listening to ASHP official, the voice of pharmacists advancing healthcare. Be sure to visit ashp.org/podcast to discover more great episodes, access show notes, and download the episode transcript. If you loved the episode and want to hear more, be sure to subscribe, rate, or leave a review. Join us next time on ASHP official. [Music] [BLANK_AUDIO]
