Conflict Management: I Don't Remember Learning This in Pharmacy School

"All polishing is done by friction."—Mary Parker Follett

Conflict is defined by Merriam-Webster Dictionary as a mental struggle resulting from incompatible or opposing needs, drives, wishes, or external or internal demands. While most pharmacists don't actively seek out conflict, it is inevitable that therapeutic decisions made over the course of a patient's stay may not follow standard clinical practice guidelines or tertiary literature. In these situations, pharmacists may need to actively intervene to prevent patient harm.

An article by the Institute for Safe Medication Practices (ISMP) titled Are you well positioned to resolve conflicts with the safety of an order? discusses a case in which an Ohio physician was accused of hastening the deaths of 14 patients by prescribing large doses of opioids. In several instances, the physician prescribed fentanyl doses as high as 2000 mcg even though staff had concerns regarding the safety and efficacy of these practices. Ultimately, the physician was acquitted of homicide; however, many pharmacists and nurses lost their jobs in the process.

While this represents a more extreme case of conflict that may arise regarding the safety of an order, the underlying issues exist in all settings. Issues such as intimidation by a prescriber's reputation or disruptive behavior may prevent pharmacists from escalating their concerns. Additionally, pharmacists may feel they do not have sufficient knowledge or training to oppose the prescriber's order and instead choose to assume the order is correct rather than initiating dialogue. Furthermore, blatant dismissal of safety concerns or imprudent rationalization of therapeutic selection may lead to insufficient consideration of pharmacists’ concerns, therefore pressuring pharmacists to accept an order or dispense a drug.

Here are a few steps you can follow to address concerns with the safety of an order:

#1 Gather Information

Gather factual, objective information that supports your concerns. This may involve reviewing the patient's chart, gathering drug information resources, and consulting other health care professionals. Preparing this information prior to the conversation will help you more clearly communicate your concerns.

#2 Question the Order

Use a standard communication strategy such as SBAR (Situation, Background, Assessment, Recommendation) or TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety) to help frame the discussion and express your concerns. Inquire about any protocols or primary literature that supports the prescriber’s therapeutic choice.

#3 Escalate the Concerns

If the prescriber will not change the order, and you are still not satisfied that the patient will not be harmed, escalate the concern. Utilize the formalized escalation process if available in your institution. See the image to the right for an example of a formalized order escalation process for navigating the prescriber chain of command. If an escalation process is not in place, work with your pharmacy leadership team to develop an established escalation process to resolve disputes.

ISMP has learned of practitioners involved in fatal errors who live with regret because they did not intervene. These practitioners encourage that you speak up and be persistent if there is any concern for patient safety.

Reference:
Institute for Safe Medication Practices (ISMP). Are you well positioned to resolve conflicts with the safety of an order? Learning from a physician’s homicide trial and the firing of multiple healthcare workers. ISMP Medication Safety Alert! Acute Care. 2022; 27(10):1-3.