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Poor Practice Can Have Patient Safety Consequences

Rxpert Solutions > Blogs > Poor Practice Can Have Patient Safety Consequences

One of my main focuses in these blog posts is drug diversion. Unfortunately, there are many hospitals out there who don’t monitor for drug diversion, whether large hospital entities or independent stand alone hospitals. If a hospital does not monitor for drug diversion, they would also not be monitoring for, by default, poor practice. When I say “poor practice” I am mainly talking about nurses, but one could certainly identify a poor practice within the pharmacy as well. Poor practice is a survey finding risk because it most likely means hospital policies are not being followed, and it can be a patient safety risk as well. Sure, sometimes we stumble on a poor practice issue in talking with staff or investigating a medication error, but until we actually audit nursing activity, we will not have a comprehensive picture of nursing practice. Sometimes the poor practice will be a work around and actually lead you to improvements the staff has known for a long time was needed. Sometimes the poor practice will be lack of knowledge or plain risky behavior that has developed over time, and sometimes poor practice actually ends up being diversion.

A few examples of poor practices I have identified when starting a diversion monitoring program:

  • Long delays in waste
  • Long delays in charting administrations
  • Charting administration prior to med removal
  • Re-use of single dose syringes
  • Routine failure to chart pain scores for as needed pain medications
  • Routine use of multiple CNS depressants at the same time
  • Routine nurse hand off (the nurse who removed the medication is not the nurse who administers)

Sometimes I’ll find the poor practice is unit wide, meaning that is the practice on the unit as a whole. Other times, the poor practice seems to be restricted to an individual. Either way, it needs to be changed in order to be in compliance with policies, improve patient safety, and take one step closer to identifying possible drug diversion. If you can’t get your hospital administration to come on board with drug diversion monitoring, consider shifting your focus to poor practice monitoring.

Our References

Terri is absolutely phenomenal. She is an incredibly knowledgeable pharmacy resource. As the medication safety officer, the quality initiatives she implemented not only impacted the patients at our medical center but also reached into the community. Terri is a genuine professional who upholds accountability while creating community among her team members. She is a great listener to identify friction points and has actionable ideas to implement improvements.

T. Eagle. MBA, MLS(ASCP), CLS Lab Operations Manager

Terri is an expert at prospective risk identification -Failure, Mode and Effects Analysis (FMEA). Terri participated in CHPSO Patient Safety Safe Tables and was part of the Hospital Quality Institute’s Regional Quality and Patient Safety Leader Network.
She is an excellent public speaker and communicates well with public and professional audiences. I look forward to her continued work in medication safety.

Regional Quality Network at HQI

Terri has done a tremendous job with the controlled substance diversion program. She has had such a positive impact and has really made the hospital a safer place.

Tri-City Medical Center
Nurse Manager

We would not be where we are with the improvements we have made with opioid prescribing if it were not for Terri driving the process.

Tri-City Emergency Medical Group
Chief Physician

In addition to understanding the ins and outs of the [controlled substance use] process completely, she is very proactive in coming to me with provider issues that she detects. She truly balances the administrative duties and the regulatory components demand with a keen sense of what my practitioners do and what their needs are on the ground. Terri is instrumental in working with my department, balancing patient care, cooperation, ability, and integrity to get the job done.

UCSD Medical Center
Chief Anesthesiologist

Terri is knowledgeable and effective in pharmacy leadership. She has the ability to be able to anticipate and prepare for the future. Her ability to utilize resources effectively in this changing environment is a strong asset. She can adapt, evolve, mentor and still never say “no” when asked to assist. She exhibits great abilities to be flexible and is a “self starter”. She has a pleasant yet effective demeanor that commands results.

Candace Fong, Pharm D
System Director of Pharmacy and Medication Safety Common Spirit Health

Terri has always impressed me as being very smart. resourceful, creative, and easy to work with. Terri’s commitment to medication safety permeated our organization, raising the awareness of this important issue throughout all levels of the institution. Terri has always been engaged, cooperative, and generous with her time.

Cary Mells, MD
Chairman of the Department of Emergency Medicine Tri-City Medical Center

Terri has done more for the Pharmacy in her few months as Interim Pharmacy Director than any other Director has done during my 12 years here.

Anita Kennedy, MBA
VP of Ancillary Services Methodist Hospital

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Address: 950 Boardwalk Suite 305, San Marcos, CA 92078

  • 760.705.4078
  • tvidals@rxpert.solutions