VA pharmacists Dr. Jennifer Bronzell and Dr. Iraida Perez are committed to continuous process improvement through a culture of safety that leads to zero patient harm. They serve at the North Florida/South Georgia Veterans Health System (NF/SGVHS).

The pair recently caught what could’ve been a potentially serious patient safety issue caused by the lack of a proper measuring device for the dose on an oral liquid medication used to treat insomnia and depression.

“We were working in the outpatient pharmacy dispensing medication when Jennifer noticed a discrepancy between the way the prescription was written and with the markings on the dropper included by the manufacturer” Perez said.

New FDA regulations require that the medication be dosed using milliliters, but the manufacturer included a dropper that indicated dosing in milligrams.

“There was no way for the patient to appropriately dose the medication,” said Lisa Zumberg, co-chair of the medication safety committee. “The potential risk to the patient may have led to serious adverse side-effects.”

Made warning signs and updated database

Once the concern was reported to the health system’s medication safety hotline, a chain of events unfolded. Now the National Center for Patient Safety and the Institute for Safe Medical Practices looking into ways to improve the safety of administering the medication.

“When the problem was initially identified, we reported the concern to the medication safety team,” Bronzell said. “Additionally, we made a warning sign for our shelf to include an oral syringe with the order and had the drug file database updated so the pharmacy software displayed a warning as well.”

Further steps were taken to identify every Veteran that had been prescribed the medication across the network.

“Example of the great care Veterans can expect.”

Local facility pharmacies began filling their prescriptions providing the appropriate oral medicine syringe. And pre-filled medicine syringes were provided to in-patients.

“The actions taken by these pharmacists demonstrate robust safety measures being taken in a just culture for reporting,” said Kimberly Schnacky, VISN 8 clinical pharmacy program manager.

According to medical center Director David Isaacks, this is just one example of the health system moving toward fine tuning the great care that Veterans can expect to receive at the North Florida/South Georgia Veterans Health System (NF/SGVHS).

“Our health care professionals work hard to minimize any potential harm, and when something doesn’t seem right, they speak up,” Isaacks said. “A culture of safety in which employees feel empowered to report patient safety concerns without fear is a practice highly regarded in the health care industry. We are proud of Dr. Bronzell, Dr. Perez, and everyone involved in reporting this patient safety concern. They are part of the driving force behind the safe care delivered to Veterans, here every day.”

About the North Florida/South Georgia Veterans Health System

The North Florida/South Georgia Veterans Health System is the nation’s largest and most complex VA health care system. It employs more than 5,800 medical professionals and support staff. The staff is dedicated to providing high quality care to over 179,000 Veterans enrolled for care.

The organization operates 14 facilities, including two medical centers located in Gainesville and Lake City. It also operates a domiciliary and clinics located throughout a 50-county service area.

By Melanie L. Thomas is a public affairs officer with the North Florida/South Georgia Veterans Health System

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Published on Sep. 30, 2021

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