It’s 4.30, you’re eyeing the clock thinking you’re on the home stretch. Then it happens… Mrs Smith comes back in… “um…I got home and I realised I have this bottle, Antenex 5mg instead of Minax 100mg. I think you got this wrong.” Your heart is pumping, maybe they gave you the wrong script, but no…an incorrect selection and a major dispensing error has occurred. Thankfully, she realised before she took any.
You ask the inevitable question, “how did this happen?”
Let’s look at this… the goal of every pharmacist when dispensing is undoubtedly to dispense the right medication safely and accurately and get it back to the right patient. But, even with the best of intentions, we sometimes fall short. On this note, James Clear has a powerful piece of wisdom.
‘You don’t rise to your goals you fall to the level of your systems.’
James Clear
This rings true here and the options for system failure are endless. For example, the PDL guide to good dispensing wasn’t followed, the pharmacist got interrupted midway through the check and started again in a different spot, the pharmacy assistant didn’t cross-check who they were handing the script out to, and the medication was put on the wrong shelf or the right drug got put into the wrong basket. Really, nearly every reason you can come up with can be attributed to failure to comply with the system, or…one is not in place.
When we are leading our teams, vision and goals are important, and an appreciation of values and the parameters for psychological safety are imperative. But, it is our systems that set the benchmark of whether we reach a goal or consistently produce good work, day in, day out.
Where does this leave you and your workplace? Five tips
If you’re looking around your pharmacy thinking, ‘our systems aren’t great, but where do I start?’ Here are five tips to consider when you are reviewing your systems and optimising the likelihood of staff compliance with them.
Make sure they are clear
Systems must be clear. There should be no wiggle room for different interpretations. How can you make them more clear? Is the wording succinct? Are the pictures or diagrams required? Could a video assist understanding?
Make sure they are actionable and accessible
A perfect system is no good to anyone sitting on the top shelf collecting dust. A perfect system is also not perfect if it is not actionable. Does the current system require five staff at all times but you only ever roster on three? Do people who should be using the system have the appropriate resources to implement the system? When we fail to provide what is needed for a system to work, we inevitably set people up to not comply. With this being so, what can you do to make your systems actionable and accessible?
Make sure they are understood
Adequate training is a must. Communication and support, like always, are critical components of good execution. Spend the time making sure your staff understand why the system is important, how it is to be executed, and the end result. How will they know if the system is being followed? What are the outcomes that will be achieved?
Make sure they are reviewed
As time rolls on, circumstances change and workplaces evolve. A system that served you six months ago may not serve you today. Making sure you review your systems regularly ensures that the system continues to be clear, appropriate, accessible and understood. In addition to regular reviews, a review of the system should be completed when an incident occurs. What part of the system broke down and why? Is it a lack of understanding, resources or something else? The response of, ‘I was too busy,’ or, ‘it was just an accident’ may flag where the problem lies. Taking the time to find these breakdowns can help to improve the system or ensure the gaps in its execution are at least addressed.
Make sure there is an opportunity for feedback
While the system may be perfect in your eyes, the people who use the system every day will inevitably see opportunities to improve efficiency and adherence or further mitigate risk. They may also see flaws, where there are inadequate resources or where the system is becoming difficult to action. Inviting staff to provide feedback on the systems they use every day is a great way to not only improve the system but also show you much you value your staff and what they bring to the table. Like always, how much is spoken about will depend on how the team perceives you will take the feedback. The level of psychological safety in your team as well as your leadership skills and emotional intelligence will underpin the success and transparency of these conversations.
Systems and the future of pharmacy
While we look to the future and discuss opportunities for increased scope of practice for community pharmacists, possibilities around changing pay structures and the advancement of our industry as a whole, the systems we create and come to rely on, will inevitably form a crucial piece of the puzzle. Today, we can begin to build the systems we need to function safely and effectively right now. In doing so, when the next opportunity comes along, we will have a back catalogue of skills ready to draw on to create the next set of systems, we and our teams need to reach our full potential.
