Leading the way to zero patient harm - North Florida/South Georgia Veterans Health System
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North Florida/South Georgia Veterans Health System

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Leading the way to zero patient harm

Dr. Perez discussed a medication discrepancy with Dr. Bronzell in the outpatient pharmacy at the Malcom Randall VA Medical Center located in Gainesville, Fla.

Dr. Perez discusses a medication discrepancy with Dr. Bronzell in the outpatient pharmacy at the Malcom Randall VA Medical Center located in Gainesville, Fla.

By Melanie L. Thomas, MBA, Public Affairs Officer
Tuesday, September 21, 2021

North Florida/South Georgia Veterans Health System (NF/SGVHS) Pharmacists Jennifer Bronzell and Iraida Perez are committed to continuous process improvement through a culture of safety that leads to zero patient harm.

The pair recently caught, what could’ve been, a potentially serious patient safety issue caused by the lack of a proper measuring device for the dose on an oral liquid medication used to treat insomnia and depression.

“We were working in the outpatient pharmacy dispensing medication when Jennifer noticed a discrepancy between the way the prescription was written and with the markings on the dropper included by the manufacturer” said Perez

New FDA regulations require that the medication be dosed using milliliters, but the manufacturer included a dropper that indicated dosing in milligrams.

“There was no way for the patient to appropriately dose the medication,” said Lisa Zumberg, co-chair of the medication safety committee, NF/SGVHS. “The potential risk to the patient may have led to serious adverse side-effects.”

Once the concern was reported to the health system’s medication safety hotline, a chain of events unfolded that now has National Center for Patient Safety (NCPS) and the Institute for Safe Medical Practices (ISMP) looking into ways to improve the safety of administering the medication.

“When the problem was initially identified, we reported the concern to the medication safety team. Additionally, we made a warning sign for our shelf to include an oral syringe with the order and had the drug file database updated so the pharmacy software displayed a warning as well,” said Bronzell.

Further steps were taken to identify every Veteran that had been prescribed the medication across the network and local facility pharmacies begun filling their prescriptions providing the appropriate oral medicine syringe, and pre-filled medicine syringes were provided to in-patients.

“The actions taken by the pharmacists at NF/SGVHS demonstrate robust safety measures being taken in a just culture for reporting,” said Kimberly Schnacky, VISN 8 Clinical Pharmacy Program Manager.

According to NF/SGVHS Director, David Isaacks this is just one example of the health system moving towards fine tuning the great care that Veterans can expect to receive at NF/SGVHS.

“NF/SGVHS health care professionals work hard to minimize any potential harm, and when something doesn’t seem right, they speak up,” said Isaacks. “A culture of safety in which employees feel empowered to report patient safety concerns without fear is a practice highly regarded in the health care industry and we are proud of Dr. Bronzell, Dr. Perez, and everyone involved in reporting this patient safety concern. They are part of the driving force behind the safe care delivered to Veterans, here every day.”

About the North Florida/South Georgia Veterans Health System
NF/SGVHS is the nation’s largest and most complex VA healthcare system employing more than 5,800 medical professionals and support staff dedicated to providing high quality care to over 179,000 Veterans enrolled for care. The organization operates 14 facilities to include two medical centers located in Gainesville and Lake City, a domiciliary and clinics located throughout a 50-county service area. 


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