Medication Safety Certificate

Accreditation for Pharmacists and Pharmacy Technicians

The American Society of Health-System Pharmacists is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.

Accreditation for Physicians

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of the American Society of Health-System Pharmacists and the Institute for Safe Medication Practices. The American Society of Health-System Pharmacists is accredited by the ACCME to provide continuing medical education for physicians.

Accreditation for Nurses

This nursing continuing professional development activity was approved by the Maryland Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation.

Certified Professionals in Patient Safety (CPPS)

This activity meets the criteria of the Certification Board for Professionals in Patient Safety for up to 41 CPPS CE hours.

This self-paced, online professional certificate is intended for pharmacists, physicians, nurses, pharmacy technicians, and other healthcare professionals responsible for improving the safety of medication use in their respective practice settings.

Scope and Background of Medication Safety

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1. Describe historical and contemporary approaches to promoting medication safety.
2. Explain the most common types and causes of medication errors.
3. Differentiate between active and latent failures.
4. Identify system-based causes of medication errors.
5. Identify the ten ISMP Key Elements of the Medication Use System.
6. Define common medication safety terms.
7. Differentiate the roles of healthcare, regulatory, and accreditation organizations focusing on medication safety.
8. Identify three important findings from the case study that require additional investigation.
9. Apply appropriate thought process to medication error analysis acknowledging characteristics consistent in all errors.

The American Society of Health-System Pharmacists designates this enduring material for a maximum of 3.0 AMA PRA Category 1 Credits^TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

This nursing continuing professional development activity was approved by Maryland Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation to award 3.0 contact hours.

Leading and Managing Change

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1. Explain the integration of medication safety into an organization’s strategic plan.
2. Identify Kotter’s eight steps for leading change.
3. Apply Kotter’s eight steps for leading change to medication safety initiatives.
4. Discuss factors that promote the diffusion of innovation and spread of change.
5. Identify skills of an effective medication safety change agent in a complex health care environment.
6. Recommend methods used to influence and engage key stakeholders in medication safety initiatives.
7. Explain effective conflict management techniques used to build successful interprofessional teams.

The American Society of Health-System Pharmacists designates this enduring material for a maximum of 1.75 AMA PRA Category 1 Credits^TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

This nursing continuing professional development activity was approved by Maryland Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation to award 1.75 contact hours.

Strategies and Tools to Implement Change

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1. Differentiate between Six Sigma and Lean.
2. Select Lean tools that can be used by interprofessional teams to improve medication-use safety.
3. Summarize the attributes of a High Reliability Organization.
4. Identify the four skills of interprofessional teams that are core to the TeamSTEPPS® framework.
5. Explain how “people development” and “deference to expertise” lead to successful change cultures.
6. Identify methods to increase the likelihood of success when introducing change.
7. Explain common pitfalls encountered when leading change.

The American Society of Health-System Pharmacists designates this enduring material for a maximum of 2.5 AMA PRA Category 1 Credits^TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

This nursing continuing professional development activity was approved by Maryland Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation to award 2.5 contact hours.

The Impact of Culture on Safety

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1. Differentiate between highly reliable industries and healthcare.
2. Explain the recurrent themes associated with a culture of safety in highly reliable organizations.
3. Summarize how culture is the most significant influence on safety in highly reliable organizations.
4. Explain the punitive impact of an outcome-based and rule-based model of accountability.
5. Contrast a blame-free culture from a punitive culture.
6. Summarize the shortcomings of a blame-free culture.

The American Society of Health-System Pharmacists designates this enduring material for a maximum of 2.25 AMA PRA Category 1 CreditsTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

This nursing continuing professional development activity was approved by Maryland Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation to award 2.25 contact hours.

Establishing a Just Culture

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1. Compare the two key sides of Just Culture.
2. Identify the three types of behavior that can be involved in error.
3. Identify six core beliefs about the management of risk in a Just Culture.
4. Summarize how a restorative Just Culture enables support of both the first and second victims of errors.
5. Explain the value of establishing a rapid response team for second victims.
6. Contrast retributive justice from restorative justice.

The American Society of Health-System Pharmacists designates this enduring material for a maximum of 2.0 AMA PRA Category 1 CreditsTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

This nursing continuing professional development activity was approved by Maryland Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation to award 2.0 contact hours.

Managing Systems and Behaviors in a Just Culture

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1. Identify three high-leverage system design strategies that can help eliminate or reduce human error.
2. Describe the differences between human error, at-risk behavior, and reckless behavior.
3. Explain how inattentional blindness and confirmation bias can cause one to miss important information.
4. Explain the cause of five common at-risk behaviors that healthcare team members may exhibit and why these occur.
5. Differentiate between first-order and second-order problem solving.

The American Society of Health-System Pharmacists designates this enduring material for a maximum of 2.5 AMA PRA Category 1 Credits^TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

This nursing continuing professional development activity was approved by Maryland Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation to award 2.5 contact hours.

Implementing and Measuring a Just Culture

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1. Explain how interprofessional teams can use various algorithms to analyze events, risk, and both system and individual accountability.
2. Apply an algorithm as a tool to promote a Just Culture, taking into consideration the questions that must be answered.
3. Explain how an algorithm intended to promote a Just Culture can be misused.
4. Identify six key self-assessment questions that can help organizations monitor progress toward creating a Just Culture.
5. Summarize the value of surveying healthcare staff to determine the safety climate of an organization.

The American Society of Health-System Pharmacists designates this enduring material for a maximum of 3.75 AMA PRA Category 1 Credits^TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

This nursing continuing professional development activity was approved by Maryland Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation to award 3.75 contact hours.

Human Factors Engineering

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1. Explain the basics of human factors engineering concepts and methods.
2. Apply human factors engineering concepts when analyzing medication safety events.
3. Summarize usability testing and heuristic evaluation as human factors engineering methods to analyze medication safety events.
4. Explain how to use heuristic evaluation and usability testing to design medication safety interventions.             
5. Apply human factors engineering methods to evaluate medication safety interventions.           
6. Describe how human factors engineering is used to evaluate safety issues with information technology.
7. Develop a plan to address medication safety issues in your workplace using human factors engineering concepts and methods.

The American Society of Health-System Pharmacists designates this enduring material for a maximum of 2.75 AMA PRA Category 1 Credits^TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

This nursing continuing professional development activity was approved by Maryland Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation to award 2.75 contact hours.

Reactive Identification of Medication Risk

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1. Identify principles of medication safety risk identification.
2. Compare strengths and limitations of reactive medication safety risk identification.
3. Describe the direct observation method of risk identification.
4. Explain the process for using manual and electronic triggers to detect medication safety risks.
5. Identify the triggers contained in the IHI Global Trigger Tool.
6. Use the IHI Global Trigger Tool to identify adverse events.
7. Explain the types of technology data that can be used for identification of medication safety risks.
8. Apply different types of technology data to determine medication safety risk.

The American Society of Health-System Pharmacists designates this enduring material for a maximum of 3.5 AMA PRA Category 1 Credits^TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

This nursing continuing professional development activity was approved by Maryland Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation to award 3.5 contact hours.

Proactive Identification of Medication Risk

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1. Explain how process improvement and Lean methodologies can aid the interprofessional team in the identification of medication safety risks.
2. Summarize how leadership rounds can be utilized for proactive medication safety risk identification.
3. Use external resources to prospectively evaluate medication safety risks.
4. Apply failure mode and effects analysis (FMEA) for medication safety risk identification.
5. Identify the the components of a FMEA.
6. Explain the strengths and limitations of proactive medication safety risk identification.

The American Society of Health-System Pharmacists designates this enduring material for a maximum of 2.75 AMA PRA Category 1 Credits^TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

This nursing continuing professional development activity was approved by Maryland Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation to award 2.75 contact hours.

Investigation and Analysis of Medication Errors

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1. Summarize a systematic approach to the identification, investigation, and assessment of medication events including methods for managing a successful institutional event reporting program.
2. Explain the relationship between adverse drug events (ADEs), adverse drug reactions (ADRs), and medication errors.
3. Contrast examples of skill-based, rule-based, and knowledge-based errors.
4. Evaluate algorithms and tools available to assist in system-based investigations, assessment, and outcome classification of medication events.
5. Explain major steps and components of a root cause analysis (RCA) process.
6. Identify regulatory expectations for event management to protect patients, improve systems, and prevent harm.
7. Compare alternative methodologies available for conducting cause analyses.

The American Society of Health-System Pharmacists designates this enduring material for a maximum of 2.0 AMA PRA Category 1 Credits^TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

This nursing continuing professional development activity was approved by Maryland Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation to award 2.0 contact hours.

Reducing Risk of System-Based Causes of Error

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1. Explain what makes a high alert medication list an effective risk reduction strategy.
2. Explain the concept of risk reduction strategies in preventing and reducing system failures.
3. Identify four principles of risk reduction strategies.
4. Rank risk reduction strategies in order of highest to lower power (leverage).
5. Summarize the advantages and disadvantages of each type of risk reduction strategy.
6. Identify examples of each type of risk reduction strategy.

The American Society of Health-System Pharmacists designates this enduring material for a maximum of 3.50 AMA PRA Category 1 Credits^TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

This nursing continuing professional development activity was approved by Maryland Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation to award 3.50 contact hours. 

Risk Reduction Strategies and Implementing Improvements

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1. Apply appropriate risk reduction strategies and implementation plans to specific patient cases.
2. Identify three key factors that are considered during prioritization of risk reduction strategies.
3. Identify key stakeholders needed to facilitate a successful implementation.
4. Compare the pros and cons of competency development and assessment of healthcare team members.
5. Explain a process for communication and education of a change.
6. Identify the key elements of an effective dashboard for ongoing monitoring of implemented risk reduction strategies.
7. Summarize appropriate techniques for patient safety WalkRounds™.

The American Society of Health-System Pharmacists designates this enduring material for a maximum of 2.75 AMA PRA Category 1 Credits^TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

This nursing continuing professional development activity was approved by Maryland Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation to award 2.75 contact hours.

Interface Between Technology and Safety

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1. Explain specific technology solutions available to address safety concerns throughout the stages of the medication use process.
2. Summarize the benefits, improvements, and errors associated with technology solutions.
3. Explain the need for a structured system, processes, and resources necessary to promote optimization of technologies in support of medication safety.
4. Apply effective clinical decision support in computerized prescriber order entry and electronic prescribing (e-prescribing).
5. Identify three challenges related to the implementation of technology within the medication use process.
6. Evaluate the benefits and challenges associated with the implementation of technologies designed to support safe medication administration.
7. Analyze potential failure modes in technology implementation and maintenance.
8. Summarize the importance of using data to evaluate if implemented technology is achieving safety benefits.

The American Society of Health-System Pharmacists designates this enduring material for a maximum of 2.5 AMA PRA Category 1 Credits^TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

This nursing continuing professional development activity was approved by Maryland Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation to award 2.5 contact hours.

Pulling it All Together to Successfully Implement and Sustain Safe Medication Practices

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1. Identify the medication safety leader's four major areas of responsibility.
2. Identify two resources available to assist the interprofessional team in the development of a medication safety plan.
3. Explain three challenges associated with the development or execution of a strategic plan for medication safety.
4. Differentiate between active and latent failures associated with the case study event.
5. Identify three latent failures of the medication use system that contributed to the case study event.
6. Identify the key system element from the case study that had the greatest potential for error prevention.
7. Select strategies to prevent similar events in the case study from occurring in other organizations.
8. Identify two reasons a good disclosure process is important for patients and families.
9. Summarize the key components of a good disclosure that occurs after an adverse event.
10. Identify the six predictable phases of the second victim recovery process.
11. Explain three ways an organization can provide peer support to healthcare team caregivers after an adverse event.

The American Society of Health-System Pharmacists designates this enduring material for a maximum of 3.5 AMA PRA Category 1 Credits^TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

This nursing continuing professional development activity was approved by Maryland Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation to award 3.5 contact hours.

In accordance with our accreditor’s Standards of Integrity and Independence in Accredited Continuing Education, ASHP requires that all individuals in control of content disclose all financial relationships with ineligible companies. An individual has a relevant financial relationship if they have had a financial relationship with ineligible company in any dollar amount in the past 24 months and the educational content that the individual controls is related to the business lines or products of the ineligible company.

An ineligible company is any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. The presence or absence of relevant financial relationships will be disclosed to the activity audience.

The following persons in control of this activity’s content have relevant financial relationships:

• Jamie Irizarry, MS, RN, BSN 
  • B. Braun Medical Inc. - United States: consultant

All other persons in control of content do not have any relevant financial relationships with an ineligible company.

As defined by the Standards of Integrity and Independence definition of ineligible company. All relevant financial relationships have been mitigated prior to the CE activity.

This online activity consists of a combined total of 15 learning modules.

• Pharmacists and pharmacy technicians are eligible to receive a total of 41 hours of continuing education credit by completing all 15 modules within this certificate.
• Physicians are eligible to be awarded up to 41 AMA PRA Category 1 Credits^TM by completing all 15 modules within this certificate.
• Nurses are eligible to receive a total of 41 contact hours by completing all 15 modules within this certificate.

Participants must participate in the entire activity, and complete the evaluation and all required components to claim credit online at ASHP Learning Center. Follow the prompts to claim credit and view your statement of credit within 60 days after completing the activity.

Important Note – ACPE 60-Day Deadline:

Per ACPE requirements, CPE credit must be claimed within 60 days of being earned. To verify that you have completed the required steps and to ensure your credits have been reported to CPE Monitor, check your NABP eProfile account to validate that your credits were transferred successfully before the ACPE 60-day deadline. After the 60 day deadline, ASHP will no longer be able to award credit for this activity.