Kyle Hultgren

Managing Director for the Center
for Medication Safety Advancement

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

As managing director for the College of Pharmacy’s Center for Medication Safety Advancement (CMSA), Hultgren has dedicated his career to making safe medication practices a vital part of health care systems worldwide.

Kyle Hultgren

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 discoveries our faculty make. 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 is a recent example of improvement education that CMSA has taught and where?

The best example would be our work with the Veteran's Health Administration, more commonly referred to as the VA. This partnership began back in 2009, when we were offered the opportunity to co-author a program on systems redesign for a VA hospital in Indiana. This program is a collection of many tools, techniques, and methods that can be used to analyze any given process carried out in a hospital. The processes range from administering medications to delivering meal trays. Once the program looks at the process in detail, its methodology digs even deeper to offer us the ability to understand the process and the results it is giving us. If we are not happy with what we see, we have the opportunity to "fix" the problem and redesign the process to hopefully drive us to better results in the future.

This program that began in 2009 as a local partnership has since grown to a national educational effort that has reached nearly all states and educated more than 3,000 professionals. We feel very fortunate to have such a wonderful partner in the VA. We've learned as much as we have taught these past three years.

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 are some issues that you would like CMSA to focus on?

The vast majority of what we do now is with health professionals, but 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 brought it back this year and we'll continue to offer it in the future. 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.

CMSA is very enthusiastically pursuing opportunities around the world. We have long recognized that we do not have all of the answers to the many issues for which we pursue solutions. Therefore, in the past year we have begun a global knowledge development and exchange program that has truly enhanced our perspective of all of the work we do. This has taken us to Sweden, the United Kingdom and will place us in Kenya this summer. We offer our insights and share the work that we have done, but we also show up to listen, to learn and to bring that experience home and to translate these safe practices into our daily pursuits.