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Medication Safety Spotlight

Mary Lou Sauer - Medication Safety Officer, AMITA Health Adventist LaGrange Memorial Hospital

How did you become interested in medication safety?
Throughout pharmacy school, I looked for areas where I could best apply my skills beyond the therapeutic side of pharmacy while being both motivational and innovative. At that time, medication safety was not a common topic discussed by healthcare professionals, even though it has always been an important area of which to pay attention.

Successful treatment depends on following prescribed treatment plans as closely as possible. If patients do not do so, the therapy will not be effective, resulting in treatment failure and even ER visits. I decided that this was an area that I wanted to contribute to, focusing especially on storage and administration techniques.

What advice would you give to pharmacy students about medication safety?
Pharmacists play an important role in healthcare overall because we are the medication experts. We complete an extensive curriculum to provide us medication-related management expertise. When evaluating therapeutic drug regimens, we take into account contraindications, side effects, and dose adjustments. However, incorrect medication administration, storage and dispensing are also harmful to patients too. As pharmacists, we should be equally mindful of these drug considerations wherever we practice.

I have a story that illustrates my point. Some time ago, when pharmacists were introduced to the Emergency Department at my hospital, a main role we filled was to obtain accurate medication histories. One patient that I met was lovingly cared for by her husband. She came into the ED feeling weak and dizzy and it was discovered that she had heart rhythm irregularities. After further questioning, her husband told me that he gave her doses of phenytoin suspension using a shot glass! I suggested that we measure a phenytoin level for the patient and discovered that the patient suffered, at least in part from, a medication induced cardiac arrhythmia.

So, if there is an opportunity to talk with a patient, do it. It might sound boring or unnecessary, but patients need your help. Help them know how to take their drugs correctly to help insure successful treatment and avoid medication related misadventures.

What do you think is the greatest medication safety challenge for new practitioners?
I think the challenge is in maintaining adequate communication. Medication safety is not solely a pharmacist’s job. It is a healthcare job that requires team cooperation. Personal communication between healthcare disciplines is challenged in the face of technology. In an effort to address this, AMITA Health has started an initiative which employs Safety Coaches to advance safety initiatives. The first safety technique presented was: STAR. It stands for “Stop, Think, Act, Review”. This encourages us, as a healthcare team, to work together when medication safety concerns are identified. Efforts such as these will help produce safer medication use.

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