Purdue Profiles: Kyle Hultgren

January 11, 2012

Kyle Hultgren, managing director for the Center for Medication Safety Advancement (Purdue University photo/Mark Simons)

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From teaching hands-on simulations and giving guest lectures to attending national conferences, Kyle Hultgren spreads the word on medication safety well beyond the borders of West Lafayette.

Hultgren was working as a pharmacist when a tragedy caused by a serious medication error forced him to evaluate the health care system that he was a part of. Now, as managing director for the College of Pharmacy’s Center for Medication Safety Advancement (CMSA), Hultgren has dedicated his career to continuing the national conversation on safe medication use practices.

How did you become interested in medication safety?

After I graduated from Purdue, I took a staff position at a large hospital in Indianapolis. While I was there, a dispensing error at one of our sister hospitals led to the misuse of heparin, a powerful blood thinning drug, and three newborns died. It was a horrible and ultimately preventable tragedy that really affected me. It made me realize that the entire system is creating medication errors, not individuals. From that point forward I volunteered for any initiative focused on process improvement. After I worked internally at the hospital for a couple of years, Purdue offered me the opportunity to focus on medication safety and process improvement full time. I jumped at the chance and never looked back.

What does CMSA do?

We want to be involved with any project or organization that is working to make medication safety a vital component of the health care system. We want medication safety to be a part of every thought, not merely an afterthought. One important area we focus on is acting as a delivery arm for some of the discovery our faculty makes. We're inherently interested in any faculty research that could serve as a way to reduce errors.

Education is another significant part of our focus. We travel the country to teach process improvement methods to health care professionals. To really get this point across, we use hands-on, simulation-based presentations. Through these talks, we introduce a central tenet of medication safety -- one person does not intentionally make the system bad, but rather the system was designed poorly. We use discovery and education to teach health care professionals from hospitals, clinics, pharmacies or any area of the system, methodologies and techniques to overcome these inherent flaws.

What do you do in your role as managing director of CMSA?

In addition to providing daily administrative functions, I get to travel and teach the simulation-based presentations around the country. When I'm on campus, I also guest lecture to doctor of pharmacy students while also co-teaching our eight-week elective course solely devoted to medication safety. On a wider scale, I craft the vision of where we need to be, sort of like laying down the road map.  My responsibility is to make sure that wherever there is an organization, presentation or even conversation about medication safety, CMSA is there and ready to contribute. I am very fortunate to have the generous support from a Lilly Endowment grant, which allows us this wide reach around the country, so that we can participate in dialogue nationwide. As a team, while we are interested in what people want to know right this very moment about medication safety, we also want to focus on what they are going to need to know tomorrow.

How does being at Purdue enhance CMSA's contributions to research and education on medication safety?

We have access to many resources that no one else does. Purdue is certainly one of the most outstanding organizations where this Center could possibly exist. We have a wonderful climate and a very supportive college and university with a visionary plan that helped establish our path. We get the opportunity to be creative and sort of toe the line a little bit on what is considered common practice when it comes to education.

For example, we recently had the opportunity to work with the School of Industrial Engineering. They supplied us with truly unique ideas about the field and more specifically about how human factors affect health care. We focused on how humans interact with their environment, computers and machines in the health care system and how that interaction could be made more effective. How does this a piece of technology interact, not only with the medications, but also with the professionals that are utilizing it as a way to improve safety? This partnership with the School of Industrial Engineering established a more efficient focus on the human-technology interaction within the entire system.
What are some issues that you would like CMSA to focus on?

 The vast majority of what we do now is with health professionals. This isn't necessarily by design and so we'd love to extend our focus. For example, we would like to begin to look at patient use of meds and how to adequately disseminate safe usage practices.

We're also excited to continue work with the doctor of pharmacy students here at Purdue. Last spring, we piloted an eight-week, one-credit medication safety elective. The students were wonderful and gave us great feedback, so we're going to bring it back next spring. In the class, we focus on root cause analysis from a systems-based perspective. We want our students, and ultimately every health care professional, to move away from the current shame and blame mentality to analyzing the system as a whole. We want don't want to identify only who made an error, but really focus on why it happened.