Preventing Medical Errors in Hospitals through an Endowed Professorship

What kind and how much medication a patient receives can be a matter of life or death.

That’s why Bob Crisafi, Ph.D., who received his doctorate in pharmacy from the University of Florida in 1956, has spent his career focused on patient safety and the role pharmacists can play in reducing medical error rates in hospitals.

He dedicated his career to developing better ways of packaging and dispensing medication in hospitals, and he founded 12 successful companies over the years that have designed innovative systems to improve drug distribution.

“For the past 40 years, my passion has been to play a role in lowering the drug error rate in our nation’s hospitals,” said Crisafi. “I want my university, the University of Florida, to carry on my vision.”

Barbara & Bob Crisafi

Through the sale of their Boston home deeded over to UF, Bob Crisafi and his wife, Barbara, donated $1 million to the college to create a chair in the department of pharmaceutical outcomes and policy to look at how medication is administered in a hospital and to create systems that will prevent medication errors.

The gift established an endowed chair at the College of Pharmacy that will work in conjunction with Shands HealthCare to generate new studies and processes to further reduce drug errors at hospitals. The goal is to improve patient safety not just at Shands but also at hospitals throughout the U.S.

“Bob’s passion is safety,” said Alan K. Knudsen, director of pharmacy services at Shands at UF. “I think his passion lines up perfectly with the university’s and Shands’ core missions.”

Richard Segal, Ph.D, a professor in the college’s department of pharmaceutical outcomes and policy, holds the new chair and will use funds generated by Crisafi’s gift to examine how new technology can be used to reduce medication errors.

“We’ll do rigorous research to thoroughly conduct an evaluation of the benefits in terms of reducing medication errors and improving patient outcomes,” Segal said.

Medication errors began to increase in hospitals in the early 1950s and ’60s, Crisafi said. Physicians would typically write a prescription order and the nurse would interpret the order, measure out the dosage from the floor’s drug closet and administer the drug to the patient.

“The nurses were really doing the pharmacists’ work,” he said.

Arguing that a better process was needed, Crisafi pioneered unit dosing, which involves a pharmacist interpreting the prescription and dispensing the drug in a repackaged, personalized dose for the nurse to administer to the patient.

Crisafi is also an advocate of electronic bedside point-of-care improvements, such as medication barcoding, which can track drug administration. Before giving a patient the medication, the nurse scans the patient’s wristband and the barcode on the medication to ensure they match correctly.

Studies conducted in the past 10 years have confirmed that medication errors in hospitals today are still common. One such study reported that one-fourth of the adverse effects of medication administered in the hospital were preventable, resulting from errors.

Researchers today like Segal are taking a serious look at health-care technologies as a new strategy for preventing medication errors.

Bar-code verification, commonly used in other industries and electronic physician prescription entry have been shown to reduce errors by more than 50 percent, Segal said.

Segal & Crisafi

For Segal, working and collaborating with Shands at UF, as part of a larger health science hospital setting, presents abundant opportunities to investigate and verify the effectiveness and best-use practices of bar-code technology to improve patient safety at the bedside.

Crisafi hopes his gift will ultimately lead to hospitals adopting new procedures that will dramatically reduce medication errors, which are estimated to kill thousands of people annually.

“By continuing this research…I hope more hospitals will change and less people will die,” he said.