Commencement address
Mercer University School of Pharmacy
Saturday, May 3, 2008
Michael R. Cohen, RPh, MS, ScD, DPS
President Underwood, Dr. Fleming, Dean Matthews, distinguished members of the faculty, graduates, parents, families and friends. Let me start out by offering my heartiest congratulations to all of you, and especially the graduates. And thank you for giving me the great pleasure and honor of delivering your commencement address. I’m a pharmacist myself and it’s truly been a great career choice for me personally so I hope you will be able to say the same thing at my age.
It’s funny how things work out in life. Like a lot of pharmacists of my generation, I became interested in pharmacy by working as a drug store delivery boy and a pharmacy assistant during pharmacy school. I loved my work in community practice and was even offered a great job as a pharmacist at that store. But just a week after graduation, I received a call at work from one of my professors – a hospital pharmacy professor and Director of Pharmacy at Temple University Hospital named Neil Davis. I’d taken a hospital course with him and also participated in the very first rotation in clinical pharmacy ever offered at the school. I guess my professor must have seen something in me that I didn’t know I had, because the call was about me coming to work at the hospital. They were just starting a clinical program with a satellite pharmacy and he offered me the position of clinical pharmacist. I flatly refused the offer because I thought back about my school days when I was sent me to the hospital’s nursing units on my “clinical rotation.” That was once a week on Fridays. Basically I’d end up standing in a corner waiting for someone to talk to me. Doctors and nurses had no understanding at all about what pharmacists might be able to offer to the clinical team nor did they care. So I basically stood and observed. No one would acknowledge me. What a terrible feeling, week after week. This memory convinced me that I was not going to leave the friendly confines of the neighborhood pharmacy and all the appreciative customers.
There’s something to learn from that story about seeing the bigger picture. My professor was persistent, calling me again and still receiving no for an answer. So what do you think he did? He called my wife at home! He told her that he thought I was giving up on a chance of a lifetime – working right up on a nursing unit directly with doctors and nurses. No other pharmacists in the country would have such an opportunity. He also let her know that I’d receive appropriate education for this new position, receive a higher salary, and have a 9-5-work schedule. I’m not sure my wife bought all of the hype, but one thing she did hear was that the job was basically 9 to 5 (although as we both learned later, being a professional is never a 9-5 job). So when I went home that night, I basically learned from my wife about the new direction my career would be taking. Two weeks later I was in my new pharmacy on the Babcock Ward at Temple University Hospital, a 56-bed men’s surgical ward. This was quite unusual because until I arrived in my satellite pharmacy, pharmacy was always practiced in the basement of the hospital, far removed from patients, doctors and nurses. Pharmacists were just a voice on the other end of the phone. I started seeing my new job as an opportunity and a challenge. Here was a place where I would actually be called upon for my knowledge and be able to prove to myself and others, that the pharmacy profession could really make a difference in patient care – not just in community practice, but also in a big university hospital where some of the most famous doctors in the world were practicing.
In the late 1960s and early 70s when I was at Temple, we knew very little of the extent of the problem of adverse drug events in hospitals. But there’d already been at least one study that hinted it was a major problem. Barker and McConnell’s observational work showed incredibly high rates of error – as much as 20% of doses being delivered to patients were in error. I couldn’t believe these numbers because they seemed so fantastically high. But, when I started my work at Temple I saw first hand that there was a great deal of truth in their data. The very agents that were supposed to help patients were in fact sometimes hurting them! This was an opportunity for change.
We now know that on average, a hospital patient is subject to at least one medication error per day in the US. At least 1.5 million serious preventable ADEs occur each year and about 10,000 people die from medication errors – it’s actually said to be one of the leading contributors to death in the US. The costs alone should be a major concern for all Americans. Believe it or not, studies show that in today’s dollars, and when you take into account prescribing drugs without a medically valid indication, failure to receive drugs that should have been prescribed, failure of patients to comply with prescribed medication regimens, and lost earnings or compensation to people for not being able to carry out household duties, we’re talking about 200 billion dollars lost to our economy. This also does not include compensation for pain and suffering or errors that do not result in harm but create extra work.
It didn’t take long for me to develop collegial relationships with the doctors and nurses on Babcock since I was on the unit most of the day and my allegiance was to them. My focus was always on improving the way medications were being prescribed, dispensed, and administered and how to improve the system, rather than simply blaming people for making mistakes. I wanted to learn what we could do to change things so we wouldn’t make the same mistake. The nurses and doctors began to trust me and even confided in me when things went wrong. By then, our satellite system started to grow and establish itself throughout the hospital. I wanted to share the problems and improvement ideas with other pharmacists in the hospital and they with me. Soon everything started being funneled to me as I became assistant director of pharmacy in charge of the satellite pharmacies and clinical services. It soon hit us that the learning could and should go well beyond our hospital. Fortunately Neil was also editor of the journal, Hospital Pharmacy. He suggested that in order to do this, I could write a monthly column called “Medication Errors” and have it published in the journal. This was another new opportunity. So that is what I did. Beginning in March 1975, the monthly column was born and is still being published today, 33 years later. That reminds me to say, always look for good mentors such as I have found like Neil and the pharmacy owners and staff where I worked. Once you receive this gift, you must return the gift and become a good mentor yourself!
The Hospital Pharmacy column eventually led to a full scale national medication error reporting program which is now operated cooperatively with the USP. We also formed a non-profit agency – the ISMP, which interacts with the pharmaceutical industry and FDA to discuss how their products might contribute to patient harm merely because of the way their labeling, packaging or drug names were designed. We also work with professional societies, oversight agencies like accreditation organizations and government agencies such as state boards of pharmacies to better understand their role in preventing drug-related problems.
A great deal of progress has been made in the medication safety field since those early years when I began my career. The culture was certainly not as it is today, in fact, the subject of medication safety was still largely unrecognized by the public. There was no ER, no Dateline NBC, no Institute of Medicine (IOM) report, no Vioxx and no government investigations looking at how poorly the FDA handles drug safety issues. Unlike today, the term "medication error" was NOT a household phrase. It was, in many ways, still a perfect world in medicine made up of doctors, pharmacists, and nurses that simply did not make mistakes, or so the public thought. In fact, pharmacists were not even permitted to tell patients the name of the medication they were taking until the pharmacy boards fought to change this regulation. It even took changes in the law to allow a pharmacist to substitute a generic drug for a brand product and even to get some pharmacists to talk to patients. In my early columns in nursing journals the editors would not permit me to let patients die. The patient could experience a serious error, but they were always revived. Nurses never accidentally killed anyone. I also remember receiving discouraging comments from some in the hospital community. In one case, a hospital administrator wrote to my hospital CEO to make sure that he knew my activities of transparency embarrassed hospital staff, scared patients, and would prevent patients from seeking care. Yet this was an opportunity because it was the right thing to do to be transparent. I remain undaunted. .
I can well remember when I was asked to appear on the very first segment of the very first broadcast of Dateline NBC (March 31, 1992) to discuss several fatal error-related issues. No one spoke openly about medical errors at that time, especially to consumer audiences. That first program aired on a Monday. On the Saturday Night Live broadcast two days before the premiere, and I remember well the 30-second promo that aired nationally. As I watched, I saw my image flash quickly across the TV screen. I was pointing to a large pile of USP and FDA Med-Watch reports documenting 70 lidocaine deaths because of a poorly designed syringe that allowed massive overdoses. The announcer blurted, "Join us as we investigate misplaced faith in the medical system. Nearly 100,000 people die every year from a hidden danger -- medical errors!" I honestly did not think anyone in medicine would ever talk to me again. In reality, only good came out of it. It was clear that the deaths were due to a syringe system that was flawed, not to careless practitioners. The syringe was soon pulled off the market. This was an opportunity to educate the industry, doctors and consumers.
When I first started writing my journal column, I was faced with many barriers. From what source would I be able to gather enough material to sustain a monthly feature about actual medication errors that had, in many cases, injured a patient or even caused a fatality? I couldn’t write with just my own experiences at Temple or people would soon catch on. Although I promised that all reports would be handled in confidence and published anonymously, why would anyone ever want to risk sharing such information with me when it might wind up being published? With no track record, why would anyone trust that reporting an error to us would be a safe thing to do? Well, it did not take very long to realize that I had seriously underestimated the level of altruism provided by our pharmacy colleagues and pharmacy technicians and later by nurses, doctors, and even patients. They knew right from the very start that by sharing their stories we could investigate, analyze, and publish prevention recommendations. It was always about improving the system, not criticizing the reporters who told us about their error. These people were actually heroes who provided an opportunity for others to learn from their experience and perhaps prevented another patient from being harmed. From day one, there has never been a time when we were short on material. And this was 33 years ago, long before it was acceptable to report errors -- long before even the Aviation Safety Reporting Program had gotten under way! Of all the people that I have to thank for whatever success we’ve had, special recognition goes to those who have placed their trust in us, enough to share their stories and sometimes their grief. Their only motivation is the hope that the information they share will make a difference. I thank them and hope that you will be among them as you go forward in your careers, whether it is hospital pharmacy, community pharmacy, industry, regulatory affairs or in academia. I guarantee that ISMP staff will be there to carry on long after I am gone.
The hooding ceremony today is more than a ritual or celebration. It’s a formal acknowledgement that you as a pharmacist are taking responsibility for overseeing the medication system and keeping it as safe as possible. You also have the responsibility of maintaining your competency and you also must be willing to change practices to enhance safety and improve quality.
Keep in mind also that you can’t accomplish much in this world by yourself, so you are accountable for working as a team, not as an individual. That means developing professional relationships with the doctors, nurses and managers with whom you will be working. You must understand the role each person plays and always act professional when confronted with individuals who know less about medications use than you. In fact, that is one very important reason why your role is so important – you have to see yourself as an educator about the safe use of medications.
From community pharmacy owners and store chain managers to directors of pharmacy and all the way up the leadership chain, you must truly understand that medication errors are just symptoms of a bad system, and error prevention efforts must be directed at the weaknesses in the system, not at the individual. We must learn to differentiate human error and the short cuts we all take from time to time (and that sometimes result in an error) from reckless behavior, where the individual knows they are doing the wrong thing and that it risks harming a patient, yet they do it anyway.
The public must get involved to a much larger extent. They should be encouraged to ask questions and stay informed about their medical care. Healthcare consumers must partner in his or her care and not just blindly accept medications and treatments without a thorough understanding of the benefits and risks. We have done very little to get patients to understand how important education about prescription medications is to their health. Currently, the number one thing a patient wants when they get their prescription filled is to get out of the store as soon as possible. Many won’t want to be “counseled” because they may erroneously think it means drug abuse counseling. By law and professional responsibility we must offer this service, so that term must be changed and a consumer educational process should be initiated. Also, when you ask consumers if they have any questions, they almost always say. “No,” usually because they do not know what is appropriate to ask. One solution may be to focus consumer-counseling education on for a defined set of high alert drugs and situations. This is an opportunity for you to save lives.
And be human: Act as facilitators not barriers
I wish I could stand here and boast that much progress has been made over the past 30 years and that adverse drug events are no longer the problem they once were. Unfortunately, I can only say that, yes, we have made some progress, and a number of systems have changed for the better. But, errors and other adverse events still occur at an unacceptable frequency, causing unbearable human suffering with a tremendous financial cost. Direct-to-consumer prescription drug advertising, lack of focus and guidance by the pharmaceutical industry and the FDA on product-related issues like look-alike drug names, ambiguous labeling and packaging and dangerous medical device design are just part of the problem. There are an ever-increasing number of new drugs and technologies a proliferation of over-the-counter products introduced every year that, while certainly beneficial, also further complicate medication use. Thanks in great part to medical industry and the new drugs and technologies they’ve brought us, we are blessed with the survival of 400-gram infants in our NICUs. Our population is living longer and healthier lives. But acute and chronic conditions require complex treatment strategies. In light of these facts, much can and should still be done to enhance medication safety. I’ll give this opportunity to the pharmaceutical and medical device industries.
Keep in mind that the nurses, doctors and patients you will encounter may NOT ask you for your help. In fact, there will be times when they will even passionately disagree with your advice. But believe me, they very often require your help to keep their patients safe. So share what you have learned and be persistent. Establish and live by your ethical and moral standards early. Life is never black and white, although we may wish it were. There will be many times in your career that you will need to bend or compromise a rule to achieve the larger goal in the delivery of safe medication care. But, never abandon your higher beliefs and ethical and moral standards if a real or tacitly accepted policy or procedure is wrong. My wife calls this the Oprah feeling – you get a feeling deep in yourself and just know it is wrong. Many times it is better to just walk away and concede. You are fortunate to be working in field were it will be easy to find another position and they will be lucky to have you.
Stay idealistic. Never respond to a clinical question with a guess. Continue to read and share what you have learned. Network at work and in professional organizations. Become an active member of a professional society, (consultant, acute care, community, etc.). Discard sacred cows and use evidenced-based or collaboratively developed information when fighting battles. Some day, if your number one goal remains patient safety, you will be thanked and maybe even save a life. Maintain your desire to help others and that includes family and friends. You will get calls from near and far asking for advice. This is actually a compliment that they value your opinion. Enjoy that respect, even if you are busy. Believe me, there is no better or more professionally rewarding feeling then when you have helped another human being. This an opportunity to pay back the people who love you for all things they did for you.
Finally, do as I say, not as I do. When at work always do your best, but do not become so consumed, although it is easy to do at times, that you don’t take time for yourself. Take the time to enjoy your family and friends, travel, and have hobbies. Stay in the larger world by reading the newspaper or Internet every day, or try at least a few times a week. We feel this is important and actually test our fellows and students on current events.
As I reflect on my 40 years of my practice of pharmacy, I have witnessed a slow but positive transformation – moving a from medical patriarchy with only physicians at the helm, to a growing emphasis on practitioner and consumer teamwork with the patient as the common goal. I have gone from standing quietly in a nursing unit corner observing others conduct rounds, to the advent of the clinical pharmacist, and now acceptance of pharmacists as a full member of the clinical team. We have moved from a culture of blame to one where we’re much more likely to focus on the need for system improvements. It’s been a long road but one worth the ride. For me, it has been the most fascinating career anyone could ask for.
However, as I said, there is much more we need to do. So, graduates, the torch is now being passed on to you. My vision is of those signs we occasionally see when we drive by some large industrial plant that say, “Congratulations workers, it’s been 1025 days since our last accident.” I hope that we’ll be able to visualize, at least in our minds, something very similar in front of every hospital and pharmacy. Somehow, I know that with the fine education you have received at Mercer, it can be accomplished.
Again, let me offer my sincere congratulations on reaching your goal. My hope for you is that the feds don’t raise the interest rate on your student loan, that you have loads of success, and most of all, a truly wonderful life that is peppered with opportunities.