2. Hallmarks Personal Competence Systems Error Promotion Managerial Responsibilities Identifying Issues of Competence Rectifying Issues of Competence Training Initial Remedial Employment Action Best Practices
3. Pharmacy Competency Low Dispensing Error-Rate Critical Order Evaluation Clinical Evaluation Work habits Best Practices versus Risk Takers
4. Factors Human Mistake System Process Mistake Fails to Protect Against Errors Actively Promotes Errors Work Flow Organization Culture ~ Root Cause Error Work system ~ Work flow Investigative Flow Chart Performance of an Individual Performance of the System
5. Cultural Environment Error Free ~ Promote Safety Minimize Outcome of Error Hospital Organizations Must provide training time Employees to complete and understand their training. Major Reason Time ~ Expenses Hospitals SHARE Error Responsibility Accountability BOTH Directions
6. Unacceptable Risks Systems Problem Managerial Problem Improvement Plan Continuing Education Prioritize Performing Tasks Safely Behavior Modification
7. Education Passive ~ Engagement Failure Knowledgeable Competency Proficient Training Perform Activity and Why Time Intense Activity Cumbersome and tiring Always be never ending process Dedicated Resources People, Time and Money
8. People and Money Budget Times Hospital systems Large Nursing Education Departments and Educators Pharmacy Departments have Neitherthe People or the Resources. Employees MUST have the Opportunity to be Successful & Effective Work-Based Training Programs Why are we surprised that they fail, regardless of the systems in place?
9. Care Assurance Demonstration of Competency Established Educational Programs Measures of Performance Qualitative Quantitative
10. Decision Tree for Unsafe Acts of Culpability Managing the Risks of Organizational Accidents Pharmacist Professional Peer Review Responsibility for Self-Evaluation Senior Leadership Level Physician Level Managerial Level Staff Level
