We recently spoke with Christian Hartman, PharmD, MBA, FSMSO, founder of the Medication Safety Officers Society at the Institute for Safe Medication Practice (ISMP), about the opportunities for pharmacists as medication safety officers and how the field is evolving.
A practicing pharmacist working in healthcare for more than 20 years, Christian served as chair of a Special Commission appointed to enhance oversight of Massachusetts’ pharmacy compounding industry in the wake of a fungal meningitis outbreak associated with contaminated vials of methylprednisolone acetate that killed 64 people. During his tenure as Medication Safety Officer (MSO) of the University of Massachusetts Memorial Medical Center in Worcester, the facility had three successful Joint Commission accreditation visits with no medication management related RFIs.
The following interview was edited for length and clarity.
While MSOs are now integral members of many healthcare organization leadership teams, the role is relatively new. How have you seen the role evolve?
CH: When I assumed role of the first medication safety officer at UMass in 2003, I was one of a handful in the nation. From my previous positions in human research at Partners Healthcare with Harvard Medical School investigators, I recognized that the process and other aspects of pharmacy could be improved upon and saw medication safety as a way to do that and improve care broadly. As clinicians, we are trained to take care of the one patient in front of us, but a medication safety officer can uncover the issues beneath process errors or other safety concerns and make changes that impact a lot of lives.
In the beginning, medication safety officers lacked formal training in medication safety, so we had to be self-taught. New pharmacists entering the field learned from their peers and publications. In the intervening years, regulation and accreditation drivers have pushed the industry to formalize training in medication safety. I had opportunity in 2006 to start a non-profit organization dedicated to training medication safety officers, which grew to 1,300 members worldwide before it was acquired in 2014 by the Institute for Safe Medication Practices (ISMP). I also started the first 12-month post-doctoral program dedicated to medication safety and co-authored accreditation standards for the American Society of Health-System Pharmacists (ASHP). Both experiences helped pave the way to formalize education and training for medication safety officers.
The opportunities for MSOs have grown worldwide. Today, pharmacists finishing their PharmD can pursue specialist training such as the residency program in medication safety. Nurses, too, have become leaders in the field. While nurses take a different pathway and courses, we often hold collaborative meetings and conferences with both pharmacist and nurse MSOs.
What do you see as the major changes on the horizon for MSOs?
CH: When I started, payers and regulations didn’t prioritize medication safety as is becoming more common today. Their focus on this issue has forced hospitals to step up their medication safety efforts. Payers are demanding dedicated safety and quality programs to be put in place and for us to prove their effectiveness with clinical outcomes. In the coming years, the need for MSOs and their importance in healthcare organizations will continue to increase.
One other development may be more controversial. The healthcare industry as a whole has seen widespread and rapid implementation of IT and new workflows. When you ask large numbers of people to change how they do their work, it takes a little while to get over the learning curve, and we’re doing this across U.S. with new technology being rolled out almost continuously. Mistakes will occur which can sometimes lead to negative outcomes. Some of those issues will cause hospitals to evaluate processes, defects and adverse drug events. MSOs will play an important role in identifying problematic processes, finding errors and implementing change to help prevent errors from recurring.
We don’t want to stop rolling out technology, though, because it can also help us reduce errors. When we use it for clinical surveillance, it helps us monitor discrete data elements such as medication usage, types of medications taken, how often and when, lab tests, vital signs, and microbiology data. All that data by itself creates a haystack—it’s hard to find the needle and make determine whether an issue is going on with the patient. Clinical surveillance brings to light patients in most need of clinical intervention. While today we’re looking just at hospitalized patients, with expansion into wearables that patients can use at home, there will be some amazing innovations coming that can transform care—if we have the tools to sort through all the data.
What advice would you give someone interested in become a medication safety officer?
CH: In order to be an effective MSO, you have to understand the healthcare environment and the processes involved in delivering care. You need to spend time in clinical practice to understand every step in the medication use process and everything it takes to provide care for patients.
That broad background helps enable the MSO to identify underlying issues. When we do a root cause analysis, we find the problem is not typically one thing, but typically many contributing factors. The reality is that healthcare delivery is very complex and involves fallible human beings as part of the process. The MSO must be trained in root cause analysis and failure mode effects analysis to adequately understand risk and the underlying causes of errors in healthcare.
It’s been exciting seeing the field develop so quickly. It’s a great area for pharmacists and one that’s just going to continue to grow.
Christian is Senior Director of Clinical Research, Development and Professional Services at Wolters Kluwer Health—Clinical Solutions. He is also founder and advisory board member of the Medication Safety Officers Society, formerly American Society of Medication Safety Officers, a professional organization representing medication safety officers at healthcare organizations and principal at Lucian Health in Boston.
He serves as an assistant professor of medicine and nursing at the University of Massachusetts Medical School, an adjunct professor of pharmacy practice at the Massachusetts College of Pharmacy and Health Sciences and the University of Rhode Island, and a clinical assistant professor of pharmacy practice at Northeastern University.
Previously, Chris served as a senior research pharmacist at Brigham and Women’s Hospital in Boston. As the first Medication Safety Officer at UMass Memorial Medical Center in Worcester, MA, he created the first accredited post-doctoral residency program in medication safety. During his tenure, UMass had three successful Joint Commission accreditation visits with no medication management related RFIs. Chris also converted the organization to electronic error reporting, increased error reporting by 150% and created an electronic solution to detect potential adverse drug events using the IHI Global Trigger tool and IHI 5 Million Lives: Preventing Harm from High Alert Medications.
He received his bachelor’s degree in pharmacy from the Massachusetts College of Pharmacy in Boston and Doctorate from the University of Kansas, completed a fellowship in patient safety at the Virginia Commonwealth University and holds an MBA from the Isenberg School of Management at UMass-Amherst.
He has served as the president of Massachusetts Society of Health-System Pharmacists (MSHP) and MSHP Foundation, the ASHP Section Advisory Group for Medication Safety, ASHP Section Advisory Group for Compliance and Quality, and UHC Pharmacy Council Committee for Medication Use and Technology. Chris is a Fellow of the American Society of Medication Safety Officers.