Sunny View Memorial Hospital: a day in the life of a busy hospital pharmacy medication errors, managers, and missing medications, oh my!

Wine, Jessica N. ; Khanfar, Nile M.

CASE DESCRIPTION

The primary subject matter of this case is concerning the managerial and personnel issues in a hospital pharmacy. Focus is on the implications of mismanagement leading to localized medication errors, dissatisfied employees and a global endangerment of patient wellbeing. The case also provides insight into the behind-the-scenes of a hospital pharmacy atmosphere.

Secondary subject matter includes issues of organization and cooperation of the work force that increase the problems in the hospital. The case can be used to assist in specifically improving and understanding the function of management in a regulated healthcare setting or to generally illustrate the importance of proper leadership and organization to prevent local and global issues in the workplace.

This case has a difficulty level of two to three. The case is designed to be taught in two class hour(s), requiring three hours of preparation.

CASE SYNOPSIS

Time is 11:30am. Date is October 15, 2006. Location is Sunny View Memorial Hospital Centralized Pharmacy. Phone line 1: Emergency Room needs IV morphine STAT! Phone line 2: Surgical Room 3 still needs the syringes that were ordered three hours ago!

The incessant requests and ringing of the telephone exhaust the overworked pharmacists of the small city hospital. To add to the chaos, the hospital pharmacy manager has been insisting that the pharmacists must work even harder to prevent the errors and medication problems that have been steadily increasing over the past weeks in the hospital.

In a hectic work environment without effective guidance to reach any goals to decrease these errors is leading Sunny View Memorial Hospital down a path of destruction and failure. With an inefficient dictator-like pharmacy manager placing the blame on others and not taking control, medication orders pile up and life-threatening errors are occurring in the pharmacy and putting patient's lives at risk. The over-stressed, but experienced pharmacists are too busy to use their knowledge to correct the blatant issues that are ruining the hospital's reputation.

This case, which focuses on the local and global implications of poor management in a hospital pharmacy setting provides insight into the utility of proper management techniques in the healthcare system to enhance patient safety. Real life medication errors that have occurred in a hospital are included to further stress the importance of proper management, organization, and personnel unity and cooperation that are necessary to prevent both employee dissatisfaction and patient emergencies.

Discussion of this case will allow students to understand and diagnose the local and global problems in the pharmacy workplace environment, create goals to help reduce medication errors, and develop specific solutions to these problems using management theories and techniques.

INSTRUCTORS' NOTES

Recommendations for Teaching Approaches

Case Objectives

* Identify the symptoms of any problems at Sunny View Memorial Hospital.

* Diagnose the problem using management terms and definitions.

* Characterize the Hospital Pharmacy Manager's leadership technique based on his actions and availability to the hospital pharmacists.

* Use Hersey and Blanchard's theory to define leader and follower roles.

* Analyze possible solutions to solve the problems, keeping in mind management theories and goals.

* Examine the hospital workplace as a whole and identify problems overall.

Questions

1. Identify the symptoms of any problems at Sunny View Memorial Hospital.

Symptoms of problems found at Sunny View Memorial Hospital consist of the following:

* Medication errors are steadily increasing

* Dissatisfied and disgruntled employees

* Pharmacists working extremely long hours

Memos full of criticism

* The main goal of decreasing errors is not being reached

* Patients receiving double doses

* No upgrade in technology since the 90's

* global endangerment of patient wellbeing

* lack of organization

* lack of timeliness

* lack of modern technology

* understaffed pharmacy

* knowledgeable pharmacist unable to correct/verify orders correctly

* accurate records are not being kept

These symptoms mentioned above lead us to believe that there is a graver problem/situation at hand.

2. Diagnose the problem using management terms and definitions.

The problem in this pharmacy is mismanagement.

A. Based on Fayol's Classical Management Theory it is essential to have five management functions and in this case this pharmacy is missing all of them.

* Planning: The pharmacy manager has not formulated or implemented an action plan that will allow the pharmacy operations department to meet the goals and objectives set by the hospital. The methods and resources needed in order to accomplish the current goals are unclear.

* Organizing: The pharmacy managers' current operational model is clearly haphazard. The pharmacists are overworked and are unable to utilize their clinical skills. It seems that the pharmacy operations are inefficient and dysfunctional. Until the pharmacy operations are streamlined or additional pharmacists are hired, the statistics of the hospital will continue to decline.

* Leading: The pharmacy manager has not been successful at setting clear directives for his department staff and therefore achieves results that are repeatedly unacceptable. He has not been able to align the vision, values, mission and or goals of the organization with that of his staff. Therefore, he is a poor manager and clearly lacks the traits of a leader.

* Controlling/Evaluation: The pharmacy manager has not assessed nor analyzed the reasons for the pharmacy's failures and is unwilling to collect feedback from the staff. He focuses his frustrations on blaming the pharmacists and maintains a closed door policy.

B. The Manager/Employee Relationship models a hierarchical style of the past. In today's world, this relationship should be a partnership where rewards are shared. Currently, there is no partnership between the manager and the pharmacists. The manager has failed to convey the energy, support, empowerment and good communication that are necessary for such a relationship. This has lead the very skilled pharmacists against the entire system where they are now unwilling to perform.

C. The manager also lacks basic managerial skills necessary to get to a proposed goal. The lack of conceptual skills and human skills:

* Conceptual Skills: the ability to analyze and diagnose a situation and find the cause and effect.

* Human Skills: the ability to understand, alter, lead, and control people's behavior.

3. Characterize the Hospital Pharmacy Manager's leadership technique based on his actions and availability to the hospital pharmacists.

Based on the pharmacy manager's actions and availability to the hospital pharmacists, the only way to characterize his leadership techniques is a little bit of each technique we have learned. We consider most of his actions in the method of Laissez Faire since he is greatly hands off or absent and he believes that things will work themselves out. His pharmacy staff is very educated and capable but without the proper resources and empowerment the pharmacists are failing. On the other hand, this manager also operates with a little of bureaucratic methods. He is all about "it's not my fault" and greatly avoids responsibility. He also displays a bit of authoritarian in his communication skills only being one way. The one thing he is NOT is participative.

4. Use Hersey and Blanchard's theory to define leader and follower roles.

Hershey and Blanchard's theory states that employees vary in their level of maturity and readiness. Leaders should adjust their leadership style to match the development level of the employee (follower). Maturity is assessed in two parts: (i) psychological maturity and (ii) the ability and readiness of the employee.

Follower's Readiness Leader's Behavior

Unable and unwilling Telling: provide specific instructions and
or insecure closely supervise performance.

Unable but willing Selling: explain decisions and provide
or confident opportunity for clarification

Able but unwilling Participating: share ideas and facilitate in
or insecure decision making

Able and willing Delegating: turn over responsibility for
or confident decisions and implementation

At Sunny View Hospital, Pharmacy manager is high task focus and low relationship focus., he uses one-way communication and sees his followers as unable and unmotivated. Pharmacists are at R4, willing and able to change their work environment, but they are too over-worked to try. They also have no internal or external motivations.

5. Analyze possible solutions to solve the problems, keeping in mind management theories and goals.

To solve the problems of declining productivity and poor employee moral, the pharmacy manager might consider some or all of the following:

* Scientific management (Taylor)--focus on employees within his department and on ways to improve their productivity. e.g. The pharmacy manager should encourage two-way communication between the staff and himself. He can then utilize their feedback and input to formulate a strategic action plan to turn things around in order to achieve the goals within the four week time frame.

* According to Nelson and Economy (2003) today's managers also need to energize their employees. This can be achieved by getting their "buy in". This will inspire them to follow his action plan with a sense of urgency. He should also empower his staff by providing them with the necessary resources to get the job done. In addition to empowering his staff, he should support them while still being mindful to balance the needs of his department with the resources allocated by the organization. Communication is very important also. The manager should communicate effectively with his staff and gain their trust. Instead of a closed door policy he should convert to an open door policy.

* Administrative management (Fayol's)--focuses on the organization (pharmacy) and the ways to make it efficient. e.g. The pharmacy manager should submit a proposal to the CEO requesting a budget increase for his department. This could facilitate more pharmacy staff, automated dispensing machines, shoots that deliver medications to nursing stations on different floors and other improvements. He could also request that a Pharmacy Supervisor position be offered. This will help to motivate his staff and also help the department to achieve its goals.

* Specific steps that can be taken in order to improve the pharmacy situation:

* Try to set a meeting with pharmacy manager to formally sit down and discuss the issues going on at the pharmacy, try to come up with possible solutions and get input from him on suggestions on how to solve the issues. For example, the need to implement policies and procedures for pharmacy operations.

* Since the pharmacists are obviously capable to do the task due to their extensive training and experience, at this point we do not know if they are willing or unwilling to try to work more efficiently. The pharmacy manager can turn the responsibilities of decision making and implementing to the pharmacists. The manager can also work with the pharmacists and share ideas as well as facilitate in the decision making process.

* Create goals to help reduce medication errors

* Try decentralizing the pharmacy

* Need specific tasks for Pharmacy employees: i.e.

* need one person in charge of screening calls only. This person is to log calls stating:

--Time call received

--Priority (high, med, low)

--Room #

--Patient name

--Medication needed/Issue

--Needed by (time)

* Need technicians to look at chart above and fill medications accurately.

After filling the medication, the technician is to provide the medication order and filled prescription/medication order to the pharmacist(s) on duty.

* Need pharmacist: while the technician is filling the medication, the pharmacist can review the patients' chart and evaluate for drug interactions, dosages, contraindications, etc ...

The pharmacist is to check the filled medication for accuracy before dispensing the medication.

* After the prescription/medication order is checked by the pharmacist, the technician is to place the filled prescription/medication order in the appropriate medication cart for the technician to deliver prior to the promised time. The nurse is also to check for accuracy with the 5 R's: Right patient, Right medication, Right dose, Right route, and Right administration time.

* Consider adding an automatic dispensing machine under the pharmacy's supervision which will allow the pharmacists to spend more time on clinical issues rather than filling prescriptions/medication orders.

* Need to consolidate the medical records with the pharmacy records to avoid duplicate administration. As in most metropolitan located hospitals, faxing the information directly into the system keeps duplications from happening.

6. Examine the hospital workplace as a whole and identify problems overall

The problems of Sunny View Hospital as a whole are that the hospital's organizational structure needs to be revised. It seems that there are high expectations of the pharmacy but not enough resources, assessment, planning, organization, and implementation. There is not enough pharmacy staff and the technology is lacking. The pharmacy manager has poor management skills and is unable to utilize the available resources. He does not recognize that the problem cannot be fixed if the pharmacists do not have the time to perform their jobs efficiently and effectively. It is his responsibility to manage the department.

Jessica N. Wine, Nova Southeastern University

Nile M. Khanfar, Nova Southeastern University