One and a half million people are injured each year as a result of medication errors, and HRSA is leading the charge to reduce those numbers.

On August 14-15, HRSA brought to Washington more than 300 leading safety net providers, pharmacists and representatives of national organizations to learn how to cut patient errors and improve health outcomes by integrating clinical pharmacy services into primary care.

The occasion was the first Learning Session of HRSA’s Patient Safety and Clinical Pharmacy Services Collaborative (PSPC).

One of the 80 PSPC teams, the Northern NY Rural Health Care Alliance, is hard at work at the Learning Session. (L-R) Colleen Alexander, Patty Bishop, Ashima Butler, and Michael Sterns.

All are also involved in expanding clinical pharmacy services, which encompasses activities like counseling patients on how to take their medications safely and examining all the drugs they take to avoid dangerous drug interactions.

One of the videos shown at the meeting noted that the role of the pharmacist in a clinical setting should go beyond “making medicines” to “making medicines work” for patients.

A typical multidisciplinary team might include, for example, a medical director and nurse from a health center, a critical access hospital clinician, and a pharmacist. All teams have at least one HRSA-supported organization, and six of the teams include a Poison Control Center funded by HRSA’s Poison Control Program.

“This was not one individual’s failure, but at any point, one individual could have saved them,” she said.

As the lights came up to silence, patient advocate Jennifer Dingman, whose mother also died as a result of a medical error, appealed to the group “never to give up on patient safety...embrace it with urgency, honesty and hope.” A personal friend of Sheridan’s, Dingman spoke on her behalf, imploring participants to “embrace this partnership, because it would mean the world to her.”

To show her strong commitment to the PSPC, HRSA Administrator Dr. Betty Duke added her signature to the Collaborative’s “Contract for Results.”

“We are counting on each of you here today to be the pioneers who will chart the course for improving health care across the nation,” she said. “Team by team, community by community, primary health care in America will change. And you will lead the way.”

The seeds for the PSPC were planted as far back as 1999, when the Institute of Medicine released its landmark study, To Err is Human. In addition to their finding that more than 1.5 million injuries occur each year from medication errors, IOM also revealed that for every dollar spent on ambulatory medications, another dollar is spent to treat new health problems caused by these medications.

“This is alarming, I’m sure all of you would agree,” Jimmy Mitchell, codirector of the PSPC and director of HRSA’s Office of Pharmacy Affairs, told the group. “Clinical pharmacy services need to be an integral part of patient care.”

To underscore this point, he noted the dramatic increase in HRSA’s 340B drug discount program, through which safety-net organizations bought more than $5 billion in discounted drugs in 2007. The rapid growth in access to these drugs highlights the need to ramp up clinical pharmacy services to help patients take their drugs as prescribed and avoid harmful interactions.

Looking to the future, the next Learning Session is planned for December 3-4, followed by one in April and another in the fall of 2009.

“We are thrilled with the success of this first Learning Session,” said Denise Geolot, co-director of the PSPC and director of HRSA’s Center for Quality. “This would not be possible without the hard work of our dedicated partners, and for this we are very grateful.”

Dr. Betty Duke and HRSA Associate Administrator Dennis Williams display the Contract for Results, which Dr. Duke has just signed.

PSPC Faculty Co-Chair Art Martinez (El Rio Community Health Center, Tucson, Ariz.) (left) and Jimmy Mitchell look on as second Faculty Co-chair Todd Sorenson (College of Pharmacy, University of Minnesota), signs the Contract for Results.