PubMed · 10162080
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D Grzybowski, L A Fox. Reengineering the documentation process.. https://pubmed.ncbi.nlm.nih.gov/10162080/
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Hospital pharmacies were surveyed about policies on medication error documentation and actions taken against pharmacists involved in an error. The survey was mailed to 500 randomly selected hospital pharmacy directors in the United States. Data were collected on the existence of medication error reporting policies, what types of errors were documented and how, and hospital demographics. The response rate was 28%. Virtually all of the hospitals had policies and procedures for medication error reporting. Most commonly, documentation of oral and written reprimand was placed in the personnel file of a pharmacist involved in an error. One sixth of respondents had no policy on documentation or disciplinary action in the event of an error. Approximately one fourth of respondents reported that suspension or termination had been used as a form of disciplinary action; legal action was rarely used. Many respondents said errors that caused harm (42%) or death (40%) to the patient were documented in the personnel file, but 34% of hospitals did not document errors in the personnel file regardless of error type. Nearly three fourths of respondents differentiated between errors caught and not caught before a medication leaves the pharmacy and between errors caught and not caught before administration to the patient. More emphasis is needed on documentation of medication errors in hospital pharmacies.
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The public has long entrusted the medical profession to regulate its own practices, but our efforts to do so have been uneven. In place of rigorous, enforceable standards, we have sometimes reverted to pseudoaccountability: weak regulations that only give the appearance that we have been responsible in setting and enforcing high standards. We have failed to deal effectively with substandard practitioners, lagged in preventing medical errors, inadequately documented patient care in the medical record, slipped up in protecting patients in clinical research projects, and accepted financial arrangements with industry that may affect our judgment. In response, government has intervened, and threatens to intervene further with regulations that sometimes are excessively intrusive and cumbersome. To preserve our remaining autonomy, we must show that we are serious about protecting the public. Professional membership organizations must stop promulgating weak guidelines and offering evaluative methods to assess and regulate their own coveted members. Instead, they must turn over assessment of their members to arm's-length, disinterested groups. Regulatory programs must have provisions with impeccable standards, surveillance processes, and methods to deal with infractions. In planning new self-regulatory approaches, we should invite open discussion and genuine involvement by independent members of the public or the government to help ensure that our decisions about standard setting are not self-serving. Our profession has already lost much authority. We can ill afford to lose more.