Corporate Student Scholarship Essay
Sterile Compounding . . . How Do We Avoid Another Compounding Debacle?
Sterile compounding is an art, and the pharmacists and technicians who prepare and administer sterile compounds are the artists. As a pharmacy student experiencing my first sterile intravenous demonstration in class, I was in awe of the fluid movements and firm, deft actions of the hands working inside the hood. After my own messy first attempt, I developed an even greater appreciation for the patience, time, effort, and practice that leads to such surety and strength of work. In spite of my initial, heavy-handed, and inept attempts, labor and repetitive method eventually gave way to dexterity and skill. I believe many compounding pharmacists obtained knowledge and learned to avoid mistakes in much the same way I did, with painstaking repetition and diligence. An infallible way to reduce making common mistakes of human error is to resist the urge to deviate from accepted protocol for the sake of time or convenience. In my recent Advanced Pharmacy Practice Experience hospital rotations, I expected to be further trained in the clinical processes that would augment and emphasize what I had already been taught in my sterile compounding laboratory. Instead I was met with ‘‘real world’’ advice about how to best exploit shortcuts to minimize the time it takes to prepare certain ‘‘low-risk’’ sterile compounds. Different variations of so-called shortcuts and time saving methods were thrust upon me at each respective hospital, regardless of my objections. It is for these unwanted, unsolicited advices and tips that we see an increasing number of, often fatal, sterile compounding mistakes. I noted a dramatic difference in what I was taught in laboratory, focused and precise sterile techniques, from what I saw in practice, rushed and, often, careless procedure. Furthermore, pharmacists who rushed around to prepare X amount of sterile compounds in Y amount of time received praise and positive feedback from their colleagues, which reinforced the idea that hastening to generate more quantities is valued over the quality of work produced. Although each instructor was well intentioned, the result created human behavior that is contrary to safe compounding practices because the rewards for risky shortcuts were immediate and positive while the negative consequences were delayed or never emerged. While acknowledging that not every human error can be completely eradicated, we should also be cognizant of the fact that mistakes can be turned into learning opportunities. When errors
Journal of Pharmacy Practice 1 ª The Author(s) 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0897190014550978 jpp.sagepub.com
are identified, the blame game often begins. An atmosphere of fault and blame can lead to an environment where errors go unreported for fear of punishment. Sterile compounding settings have their fair share of errors but measures should be put in place to prevent repeating those errors. Compounding personnel and staff should be encouraged to report errors, including their own, without concern for reprisal. When the fear of unwarranted punitive action is taken away, steps can then be taken to analyze and rectify errors openly, thus allowing for more proficient sterile compounding. It should be understood that even competent professionals could make mistakes. As long as it was not an intentional disregard for rule and protocol, compounding personnel should be encouraged to identify and learn from mistakes while maintaining professional accountability. There are many contributing factors in the sterile compounding environment that can lead to dangerous shortcuts, which then become typical and commonplace practice. We must stop the habits of cutting corners in favor of meeting quantity quotas or rushing to expedite medications ahead of an imaginary personal timer or in response to an impatient health care provider’s urge to hurry. Skill is formed by the habits of consistent practice and fortified by unfailingly following correct protocol. No amount of mechanical automation, fancy color-coded labels, checklists, and double checks will replace quality care, close attention, and personal responsibility. Punishing frontline compounding pharmacists and technicians for unintentional mistakes borne of human error is also a debilitating setback for future error prevention. Errors should be seen as a learning experience and used as a lesson on how to avoid repeating it in the future. Oscar Wilde has once said, ‘‘Experience is simply the name we give our mistakes.’’ If more pharmacists and technicians working in the field of sterile compounding consciously chose to look at their sterile preparations as a work of art to be completed meticulously and thoughtfully, then there would be more experience and less frequency of human error. The only thing left then is to learn from our mistakes and resolve to be better artists in the future. Christine Thuy An Nguyen, PharmD Candidate 2015 Touro College of Pharmacy, Manhattan, NY, USA
Downloaded from jpp.sagepub.com at WASHINGTON UNIV SCHL OF MED on November 14, 2015
Sterile Compounding . . . How Do We Avoid Another Compounding Debacle?
Sterile compounding is an art, and the pharmacists and technicians who prepare and administer sterile compounds are the artists. As a pharmacy student experiencing my first sterile intravenous demonstration in class, I was in awe of the fluid movements and firm, deft actions of the hands working inside the hood. After my own messy first attempt, I developed an even greater appreciation for the patience, time, effort, and practice that leads to such surety and strength of work. In spite of my initial, heavy-handed, and inept attempts, labor and repetitive method eventually gave way to dexterity and skill. I believe many compounding pharmacists obtained knowledge and learned to avoid mistakes in much the same way I did, with painstaking repetition and diligence. An infallible way to reduce making common mistakes of human error is to resist the urge to deviate from accepted protocol for the sake of time or convenience. In my recent Advanced Pharmacy Practice Experience hospital rotations, I expected to be further trained in the clinical processes that would augment and emphasize what I had already been taught in my sterile compounding laboratory. Instead I was met with ‘‘real world’’ advice about how to best exploit shortcuts to minimize the time it takes to prepare certain ‘‘low-risk’’ sterile compounds. Different variations of so-called shortcuts and time saving methods were thrust upon me at each respective hospital, regardless of my objections. It is for these unwanted, unsolicited advices and tips that we see an increasing number of, often fatal, sterile compounding mistakes. I noted a dramatic difference in what I was taught in laboratory, focused and precise sterile techniques, from what I saw in practice, rushed and, often, careless procedure. Furthermore, pharmacists who rushed around to prepare X amount of sterile compounds in Y amount of time received praise and positive feedback from their colleagues, which reinforced the idea that hastening to generate more quantities is valued over the quality of work produced. Although each instructor was well intentioned, the result created human behavior that is contrary to safe compounding practices because the rewards for risky shortcuts were immediate and positive while the negative consequences were delayed or never emerged. While acknowledging that not every human error can be completely eradicated, we should also be cognizant of the fact that mistakes can be turned into learning opportunities. When errors
Journal of Pharmacy Practice 1 ª The Author(s) 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0897190014550978 jpp.sagepub.com
are identified, the blame game often begins. An atmosphere of fault and blame can lead to an environment where errors go unreported for fear of punishment. Sterile compounding settings have their fair share of errors but measures should be put in place to prevent repeating those errors. Compounding personnel and staff should be encouraged to report errors, including their own, without concern for reprisal. When the fear of unwarranted punitive action is taken away, steps can then be taken to analyze and rectify errors openly, thus allowing for more proficient sterile compounding. It should be understood that even competent professionals could make mistakes. As long as it was not an intentional disregard for rule and protocol, compounding personnel should be encouraged to identify and learn from mistakes while maintaining professional accountability. There are many contributing factors in the sterile compounding environment that can lead to dangerous shortcuts, which then become typical and commonplace practice. We must stop the habits of cutting corners in favor of meeting quantity quotas or rushing to expedite medications ahead of an imaginary personal timer or in response to an impatient health care provider’s urge to hurry. Skill is formed by the habits of consistent practice and fortified by unfailingly following correct protocol. No amount of mechanical automation, fancy color-coded labels, checklists, and double checks will replace quality care, close attention, and personal responsibility. Punishing frontline compounding pharmacists and technicians for unintentional mistakes borne of human error is also a debilitating setback for future error prevention. Errors should be seen as a learning experience and used as a lesson on how to avoid repeating it in the future. Oscar Wilde has once said, ‘‘Experience is simply the name we give our mistakes.’’ If more pharmacists and technicians working in the field of sterile compounding consciously chose to look at their sterile preparations as a work of art to be completed meticulously and thoughtfully, then there would be more experience and less frequency of human error. The only thing left then is to learn from our mistakes and resolve to be better artists in the future. Christine Thuy An Nguyen, PharmD Candidate 2015 Touro College of Pharmacy, Manhattan, NY, USA
Downloaded from jpp.sagepub.com at WASHINGTON UNIV SCHL OF MED on November 14, 2015
