Pharmacists,

In the past, Michele has not sent event follow-up forms to pharmacists as it relates to Sentri-7 reviews. Sentri-7s are great ways for pharmacists to make a great catch by finding mistakes that were either missed on initial verification or by finding interventions to make based on situational changes that would not otherwise cross pharmacists' path (changing renal function, HD schedule, MD plan of care, etc). We have not sent the event follow-ups to pharmacists because a lot of Sentri-7 can be clinical judgement and we don't want to give the impression that something we are doing to help patient care is an "error" made by a pharmacist. 

With that being said, we have seen an increasing number of safety events that we feel could have been caught sooner on Sentri-7 reviews. We are having trouble diagnosing and assessing the reason they were not caught and often have to make educated guesses as to why this was not caught (patient off the floor so Sentri wasn't reviewed, labs were borderline and did not warrant immediate change, miscommunication with providers, etc.). For that reason, moving forward, Michele will begin sending event follow-ups to pharmacists when we believe the event should have or could have been addressed on Sentri-7 reviews. Please understand that this is not an accusation of wrong doing or error. We instead want to understand how we as a leadership team can continue to improve upon our Sentri-7 rules, training, and processes to improve patient care. There may be very understandable explanations for what happened which would be very useful to the leadership team as it comes to our goal of continuing to improve safety on our HRO "Journey to Zero". 

If you have any questions or concerns, please don't hesitate to reach out to me our your supervisor. 

Thanks,