Avoid Pitfalls of Practice Drift

You can help keep practice drift from sneaking into your pharmacy.

It’s when shortcuts or work-arounds are commonly used...and seemingly justified...to improve efficiency or meet immediate needs. And the perception of associated risk fades away.

Some examples are barcode scanning one package multiple times instead of each package...compounding multiple types of IVs together...signing off on waste without checking what’s being wasted...or skipping hand hygiene.

This is scary because these at-risk behaviors can become the norm as other staff start to mimic them...with policies and procedures intended to optimize patient safety long forgotten.

Stay alert for practice drift...to avoid its pitfalls.

When onboarding new techs, or if you’re being onboarded, stick with policies and procedures for tasks. Don’t deviate to “the way we do it around here.”  This can help nip “bending the rules” in the bud.

When you spot practice drift, consider why it’s happening. It’s often in response to a system problem.

For instance, techs who don’t have enough time to make their hourly deliveries may double up later...leading to some meds remaining in the pharmacy for an extra hour and delaying treatment.

Report issues causing practice drift to your admin or med safety officer. In a just culture, this should trigger exploring system fixes to avoid it...and possibly coaching those involved.

Help brainstorm...and offer solutions, if needed. In the above example, workload may need to be split up differently...or meds may be able to be tubed to certain patient care units.

If you come up with a way to improve efficiency or productivity, work with your team to verify it’s safe...and doesn’t increase the risk of errors or other problems...before using it. Also check whether policies and procedures will need to be revised.

Find more ways to improve patient safety in our resource, Preventing Med Errors.

Key References

  • Patient Safety Authority. Can you (un)catch my drift?: dealing with practice drift in healthcare. October 6, 2021. https://patientsafetyeducation.org/courses/can-you-uncatch-my-drift/ (Accessed February 29, 2024).
  • ISMP. Medication Safety Alert!  Acute Care. June 18, 2020. https://www.ismp.org/resources/differences-between-human-error-risk-behavior-and-reckless-behavior-are-key-just-culture (Accessed February 29, 2024).
  • ISMP. Medication Safety Alert!  Acute Care. May 17, 2012. https://www.ismp.org/resources/just-culture-and-its-critical-link-patient-safety-part-i (Accessed February 29, 2024).
Hospital Pharmacy Technician's Letter. March 2024. No. 400325



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