In this next topic, I'll talk about an example of Proactive and Reactive Systems Thinking Strategies. And I'm going to use Johns Hopkins Hospital as an example and use as the example reviewing medication errors and how do you, from a medication use point of view make an institution as safe as it can be using proactive and reactive systems thinking. So, that would be the example I use and we first have to make sure we understand the medication use process. It's made up of many essential parts. And so, in each of these essential parts are working together to get that final outcome of excellent patient care with Medication-Use. The parts of the Medication-Use system often times people think, oh yes, medication use, that's pharmacist dispensing medicines. Well, that's true but there's many many more aspects of the Medication-Use system. And to give you an idea, here's a description. We need to get information about the patient involving past medical therapy, we need to develop and communicate therapeutic plans, we have to order, we have to prepare it, we have to administer it, we have to monitor it and we also have to have an infrastructure that supports all of this. And here are some examples of infrastructure. So, we have to have the support of leadership, we have to have the proper culture, human resources need to be adequate, information technology needs to allow people to do the correct things as easily as possible, formulary management, inventory control, policies. So, you can see that there are many many aspects of the Medication-Use system and I could have used any other system for that matter and they would had equally this many steps. So, it's very important to think of the whole process because when a medication error occurs in my example, you need to be considering all of these steps as potential contributors to that error. In the next sequence, I want to give you examples of reactive and proactive way of improving the Medication-Use System, again this can be applied to any system in a hospital. To improve the Medication-Use system and use examples of what we've used here at Hopkins and have found that it works quite well. You need both a reactive and proactive methodology. The reactive improvement, what we're doing is reacting to medication errors that had been voluntarily reported. Now, when you are reviewing your voluntarily reported errors, it's important to not take them at face value. The person reporting has done the best they can to report it, but they're not looking at the whole system through the safety lenses that you're likely to be looking at. So, a good premise is that voluntarily reported errors are incomplete. So, you really have to go and find the rest of the information. Next point, is the trail gets cold really fast. So, it's important go to where the error occurred when you're doing the review, and go there as quickly as possible after the error has occurred. So, for instance, if somebody says, oh yes I go and I review the error once a month. Reviewing an error days after that it happened, it's not likely that you're really going to find out what happened. So, it's very important to review errors in a timely way. Use holistic thinking and use a transdisciplinary group of people. Now, I'm going to go off in a little bit of a tangent here. I suspect all of us have been at meetings that are multi-disciplinary meetings. Where everybody is sitting around the table with their arms crossed, carefully guarding over their individual disciplines. Making sure that no one tries to make their discipline do more than someone else. That's not holistic thinking, that's reductionistic thinking. And a transdisciplinary group or this term transdisciplinary is this wonderful term coined by Gina Page who was a Swiss child psychologist who coined the term. And the idea here is that transdisciplinary is that me as a pharmacist as a multi discipline member, not only in my thinking about the world from a pharmacist point of view, I'm simultaneously doing my best to understand the world view of the anesthesiologist, the respiratory therapist, the nurse, the internal medicine person. So that, what we can do is to make sure that what we've changed in my area of responsibility, dovetails nicely into other people's areas of responsibility. So that, our interaction of these is central parts worked together well to produce the overall output of our institution which is excellent patient care research and teaching. So, transdisciplinary versus multi-disciplinary is a really important concept and an important one in systems thinking. In the meeting frequency, just to give you an idea, I don't think this is going to work very well if you've got a monthly meeting. And I can tell you that at Hopkins, we meet every week. And so, we have a multi-disciplinary, a transdisciplinary group that meet and we bring those errors that have been voluntarily reported. And a lot of back up, a lot of review that has gone in ahead of time, and our whole team tries to figure out whether or not we should change the system and how to change it and how do we then implement it. We keep bringing that topic back to the group until either we closed it. We've decided, you know, we don't really think fundamentally there's a problem with the system here, or it keeps coming back until we've changed the system that will hopefully decrease the chance of that error happening again. What we also do, and its's a really important issue, is let's say, we have an error that occurred in our medical intensive care unit. It's good to go ahead and implement those fixes in the medical intensive care unit. But another thing you should do, is consider where else might that error occur and implement those features, those improvements in other intensive care units before that problem occurs there. So, spread lessons learned. It's very important. Now, I'll also give you an example of a proactive way. We could keep just putting out the fires as that as we find them. If an error is reported we go try to figure out how to avoid that. But you have to try to stay ahead of it as well. So, one of the things we find in the medication management area, is that we very closely follow documents such as the Institute of Safe Medication Practices newsletter and FDA alerts. These are sources that describe problems that have happened somewhere in the country or the world and when we review that, we asked the question, could that error happen here at Hopkins? So, maybe this is an error that occurred in a Midwest hospital for instance. We would say, could that happen here? And if the answer is yes, then question is, Well, what are we going to do? What systems are we going to change to try to prevent that error from happening at Hopkins? Or to go ahead and mitigate harm should that error happen. So, it's a proactive way to try to prevent errors from ever happening in your institution to begin with. Once again, our meeting frequency to review these types of issues is weekly so that we really try to stay on top of this. We keep the issue open until we've decided not to change anything or that the system change has been implemented. And once again, we should think about all the different places where that error could happen and implement appropriate changes in all of those errors, so that we spread that learning.
