With the introduction of automated dispensing systems new safety factors appear as the pharmacist has to interface and change work-flows between dispensing assistants and the patient.
And that takes place after a complete refit of the dispensary to accommodate the new robotic equipment and its impact on work-flows.
Because of the pressures on the pharmacist through an unfair PBS system, pharmacy owners must now consider investing in this type of equipment because it will release up to 90 percent of a dispensing pharmacist’s time plus a full-time dispensing assistant.
Suddenly the risk of a dispensing error has just increased through a more remote type of dispensing, offset somewhat by a reduction in selection errors, so to minimise the overall risk a new protocol has to be developed to check the prescription input with the final output of the system.
If a simple system is not developed, there will be limited compliance with checking and all that entails.
In risk management, commercial airline pilot systems are always put forward as the “gold standard”, but it is the military pilot standard that should be adopted.
Managing complexity and rapidly changing situations are commonplace in everyday pharmacy.
Leaving the dispensary behind will be a massive culture change because the liberated pharmacist and dispensary assistant must now focus on rounding out core business – adding paid informational and cognitive services that fill a valid need and provide value and benefit to a patient.
The level of complexity within these new processes has to be very high and provide a guarantee for patient safety.
Military aircrews understand the importance of managing risk because they have to keep working in worst case scenarios, just like doctors and pharmacists.
Medicine has adopted several safety principles from civil aviation with mixed success.
Examples include regulatory processes such as accreditation and incident reporting and standardisation techniques such as checklists and the so-called sterile cockpit, which forbids non-essential activity and handover briefings.
Although treatment guidelines may benefit from standardisation, and regulation can improve the safety of medical devices and drugs, other areas, such as emergency departments and intensive care units, need to maintain flexibility to cope with developing situations.
Translating rigid civil aviation processes indiscriminately into hospitals and community pharmacies, is not always appropriate.
A better industry to consider for healthcare functions that require flexibility and autonomy is not civil but military aviation.
Civil aviation has zero tolerance for risk and will cease operating if conditions are too dangerous, such as when a volcanic ash cloud appears in certain destinations (like Bali).
However, managing risk is part of the job in military aviation.
As in healthcare, the military operates in a high stakes environment where crews with limited resources deal routinely with complex and time critical operations.
As in many areas of healthcare, personnel can be under continual pressure in unpredictable situations with external constraints.
Innovation, improvisation, and timely information are critical to success.
Military aircrew, like clinicians, learn to deal with periods of downtime, then rapidly gear up for challenges that require full concentration often for prolonged periods.
Military pilots must work close to prescribed boundaries, with less margin for error than civil pilots.
Boundaries include not only the technical limits of aircraft but also limitations imposed by the environment or mission, which can mean having to fly under high G forces or close to the ground.
The increased physical and cognitive load can be exacerbated by fatigue.
Clinicians face similar challenges in pursuit of optimum performance.
Similarities between operating theatre staff and pilots, or between anaesthetics and aviation, include operating in dynamic environments with rapid and unpredictable changes in workplace tempo, and solving ill structured problems under pressure with limited information.
This also has the feel of a busy dispensary at a peak moment.
Military aircrew learn about the limits of human performance, such as managing stress and fatigue in oneself and others, and managing attention so as not to become fixated on one task or to lose awareness of what is happening in the surrounding environment.
They are trained to plan for contingency, to prioritise tasks under rapidly changing conditions, and to maintain capability in deteriorating situations.
In particular, military aircrews know what to expect when operating at the limits of performance and how to re-establish normality.
Supervised practice of worst case scenarios in flight simulators allows crews to learn decision making under pressure.
Because they have trained for the worst, aircrew have spare capacity.
These lessons are beginning to be taught in healthcare, with training hospitals using more simulation facilities.
Community pharmacies are no different and a total systems breakdown, losing all electric power, needs to be simulated as a regular routine and included with the induction of any new staff.
In fact, new staff represent an opportunity to have a simulated practice.
But more is required.
Firstly, emphasis should be on improving adaptability and resilience of healthcare processes.
Healthcare is complex, and the timing and form of adverse events cannot easily be predicted—better access to timely information can result in improved decision making and generation of more flexible solutions.
In a pharmacy environment there needs to be a break-down protocol to cover all segments of the dispensing process, and that process may involve keeping a breakdown kit kept ready for instant use.
For example, in a total blackout, the first item of need is a battery light source and a set of back-up batteries (rechargeable batteries for preference).
The next item needed may be a manual numbering stamp to create a reference to track the dispensing item until it can be entered in the normal computer system.
The kit may also include a manual typewriter and a roll of pre-printed adhesive labels – something that does not rely on electricity.
Or a battery operated laptop fitted with a mobile Internet device may be able to bridge some of the input components, particularly if a cloud system is employed for all IT systems and records
A printed copy of the protocol describing what happens in a breakdown should be included and a tick-box checking procedure provided.
There should also be a list of contacts for repairers and technicians
Obviously battery charge levels need to be tested every three months, on a regular basis.
Military units use techniques to improve resilience including planning for the unexpected; training teams together; and recognising that the team’s knowledge is greater than that of any individual.
Tools that aid information sharing improve an individual’s awareness because, as in healthcare, military teams are dispersed and communicate electronically.
Secondly, focus should be on improving the adaptability and resilience of healthcare personnel.
Clinicians are highly trained in knowledge of physiology and disease and dispensing processes but often they are less aware of how insight into their own limitations can improve their performance.
The solution may involve supported simulation, where clinicians can experience high stakes scenarios safely, developing self awareness, planning for contingency, and communication skills.
Good clinicians develop these skills independently over time, but we can teach them early.
The aviation industry has lessons for medicine in how to improve the resilience and adaptability of medical processes and personnel.
However, military aviation may be a better model to consider than its civilian counterpart.
As collaboration is going to increase pharmacists are going to have to develop trust with other health personnel.
Having a protocol for breakdowns and other workplace disasters will help to foster trust.
On a reciprocal basis, the breakdown protocols with other professionals need to be understood and supported.
As collaboration increases the need to understand how other health environments and individuals actually work and interact and how integration may be managed for critical incidents.
Now that is really challenging and interesting work.