patient safety report pharmacy

Patient safety Patient safety incidents are unintended/unexpected, which could have, or did, lead to harm for one or more patients receiving healthcare. Pharmacy teams must report incidents, whether they result in harm or not.

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What is the purpose of a patient safety report?

PATIENT SAFETY This report may be used, in whole or in part, as the basis for development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied.

What is the new PQS patient safety report resource?

PQS: Patient safety report resource September 16, 2021 A new resource to support community pharmacy contractors to complete their patient safety report, a requirement of the ‘Safety report and demonstrable learnings from the CPPE LASA e-learning’ Gateway criterion of the 2021/22 Pharmacy Quality Scheme (PQS), is now available.

What is included in the community pharmacy patient safety group resource?

*The above Community Pharmacy Patient Safety Group resource includes an example of a completed annual patient safety template as per the requirement for previous Schemes.

How do I contact the community pharmacy survey on patient safety?

FOR TECHNICAL ASSISTANCE OR QUESTIONS ABOUT THE COMMUNITY PHARMACY SURVEY ON PATIENT SAFETY, PLEASE EMAIL SAFETYCULTURESURVEYS@WESTAT.COM . A-1 Appendix A. Sample Data Collection Protocol for the Pharmacy Point of Contact: Paper Survey Data Collection Tasks and Schedule for the Community Pharmacy Survey on Patient Safety Culture

What is a patient safety report?

Patient Safety Reporting (PSR) gives military treatment facility personnel the ability to anonymously report medical events that impact the safety of patients.

Which types of events should be reported in a safety report?

All team members are required to participate in the detection and reporting of any error, medication error, near miss, hazardous/unsafe condition, process failure, injuries involving patients, visitors and staff or a sentinel event.

What is the role of pharmacist in patient safety?

Ensuring the safe prescribing and dispensing of medication to patients is a core function of a pharmacist. Pharmacists ensure that patients not only get the correct medication and dosing, but that they have the guidance they need to use the medication safely and effectively.

What is an example of a patient safety event?

A patient safety incident occurs but does not result in patient harm – for example a blood transfusion being given to the wrong patient but the patient was unharmed because the blood was compatible. or expected treatment – for example he/she did not receive his/her medications as ordered.

How do you write a patient report?

III. Patient case presentationDescribe the case in a narrative form.Provide patient demographics (age, sex, height, weight, race, occupation).Avoid patient identifiers (date of birth, initials).Describe the patient's complaint.List the patient's present illness.List the patient's medical history.More items...•

What is patient safety in healthcare?

What is Patient Safety? Patient Safety is a health care discipline that emerged with the evolving complexity in health care systems and the resulting rise of patient harm in health care facilities. It aims to prevent and reduce risks, errors and harm that occur to patients during provision of health care.

How can pharmacy improve patient safety?

focus on patient-friendly and clear packaging and labelling. rollout of proven interventions in primary care such as the PINCERquality improvement tool. the development of a prioritised and comprehensive suite of metrics on medication error aimed at improvement, and.

How do you ensure prescription safety?

0:075:07Ten Steps to Ensuring Prescription Safety - YouTubeYouTubeStart of suggested clipEnd of suggested clipThe medication name and strength quantity of the order directions. On how you should take theMoreThe medication name and strength quantity of the order directions. On how you should take the medication. The name of the person who ordered your prescription. And the number of refills.

Who is responsible for health and safety in pharmacy?

As an employer, you have a legal responsibility to protect the health and safety of your employees and anyone affected by your activities. We can help you reduce risk and improve the wellbeing of your employees, patients, customers and any visitor to your pharmacy premises.

Why is patient safety reporting important?

It helps identify root causes: All healthcare incidents have a cause. The root causes must be identified—and corrected—to try to prevent adverse events from recurring. A patient incident report is a detailed, written account of the chain of events leading up to an adverse event.

What should be documented in the safety event report for this patient?

Filling Out an Effective Incident Report Include the full names of those involved and any witnesses, as well as any information you have about how, or if, they were affected. Add other relevant details, such as your immediate response—calling for help, for example, and notifying the patient's physician.

What should be documented in the safety event report for this patient?

Filling Out an Effective Incident Report Include the full names of those involved and any witnesses, as well as any information you have about how, or if, they were affected. Add other relevant details, such as your immediate response—calling for help, for example, and notifying the patient's physician.

What is the most common type of incident reporting event?

medication incidentsThe most common types were medication incidents (29%), falls (14%), operative incidents (15%) and miscellaneous incidents (16%); 59% seemed preventable and preventability was not clear for 32%. Among the potentially preventable incidents, 43% involved nurses, 16% physicians and 19% other types of providers.

What are the 4 elements you should try to get when reporting an adverse event to patient safety?

The minimum dataset required to consider information as a reportable AE is indeed minimal, namely (1) an identifiable patient, (2) an identifiable reporter, (3) product exposure, and (4) an event.

What is a safety event?

A Safety Event is a situation where best or expected practice does not occur. If this is followed by serious harm to a patient, then we call it a “Serious Safety Event (SSE)”.

What are the unique characteristics of a community pharmacy?

Unique Characteristics of Community Pharmacies. Community pharmacies have limited access to patients' electronic medical records. Unbeknownst to many patients and prescribers, most community pharmacists do not have access to patients' diagnoses, laboratory values, or even their entire prescription history through the electronic medical record. ...

What is the role of pharmacists in the community?

Community pharmacists, the most accessible medication experts, can play a major role in ensuring safe and appropriate medication use in community-dwelling patients.

Why are pharmacists unable to predict volume?

As a result, pharmacists are generally unable to predict the volume and complexity of their work. This leaves limited time to adequately address patient health or drug-related problems, and a limited ability to adjust staffing for patient or clinician needs. Third-party payment issues.

Can you walk into a pharmacy to get a prescription?

Patients may call or walk into the pharmacy at any time and request new or refill prescriptions. Many pharmacies also have a drive-through window for prescription drop-off and pick-up. Patients have an expectation that they will not have to wait very long to get their prescriptions filled.

Can a pharmacist rely on a patient's prescription?

To overcome this barrier, community pharmacists must rely on very limited information on the prescription itself and/or the patient's knowledge of his or her condition. Additionally, if a patient fills prescriptions at multiple pharmacies, the pharmacist may also lack access to the patient's complete medication profile.

Is a community pharmacy a for profit organization?

With the exception of community pharmacies affiliated with integrated health care systems, almost all community pharmacies are for-profit organizations. Because there is substantial competition in the marketplace, particularly for publicly traded companies, there is significant emphasis on improving profitability and market share. High-level decisions about policies and procedures, tools and technology, and hiring practices are viewed as proprietary. There is very little sharing of information regarding performance measures and medication errors, information that could help others learn from and prevent similar mistakes. This is inconsistent with the recommendation for health care organizations to improve patient safety through transparency. ( 8)

Who funded the 75Q80119C00004?

This project was funded under contract number 75Q80119C00004 from the Agency for Healthcare Research and Quality ( AHRQ), U.S. Department of Health and Human Services. The authors are solely responsible for this report’s contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S. Department of Health and Human Services. None of the authors has any affiliation or financial involvement that conflicts with the material presented in this report. View AHRQ Disclaimers

How can pharmacists influence medication safety?

Specialty pharmacists can positively influence medication safety culture within their pharmacy by promoting just culture, encouraging staff reporting of errors (inside and outside of the organization), and taking part in patient safety culture surveys.

Why do specialty pharmacies need robust programs?

Due to the high-touch, high-risk nature of specialty medications, specialty pharmacies must incorporate robust programs to ensure proper medication usage and minimize the potential for error or adverse events.

Why is it important to review published safety literature in the pharmacy?

Proactively reviewing published safety literature in the pharmacy can help promote a positive safety culture and allow the team to identify opportunities to prevent errors and patient harm. The Excelera Network, a nationwide network of health system specialty pharmacies, provides a great example of shared learning opportunities between health system specialty pharmacies through a medication safety user group that meets quarterly.

Why do specialty pharmacies share good catches?

These good catches can be shared across pharmacy departments within organizations in order to increase awareness and to recognize those promoting medication safety.

What is a just culture in pharmacy?

In a pharmacy with a just culture, there is open and honest reporting of medication safety concerns as a way to promote learning and preventing future errors and patient harm. Just culture changes the focus from errors and outcomes to system design and management of staff behavioral choices: human error, at-risk-behavior, and reckless behavior.

What is the role of a specialty pharmacist?

The specialty pharmacist has a unique role in medication safety. Not only are they responsible for ensuring safe, effective, appropriate use of specialty medications—and ensuring that the patient is educated on their therapy and can be adherent—but they also play a strong role in promoting a positive safety culture within their pharmacy setting.

How can pharmacy leaders improve reporting culture?

Pharmacy leaders and those responsible for collecting and reviewing error reports can do these things to positively impact the reporting culture: Earn the trust of reporters and ensure that those who are involved in and report errors are not punished.

Key Strategies for Improving Medication Safety: An ISMP Perspective for 2015

Michael R. Cohen, R.Ph., M.S., FASHP President Institute for Safe Medication Practices

Medication Errors: Causes and Prevention

John B. Hertig, Pharm.D., M.S. Associate Director and Assistant Clinical Professor Purdue University College of Pharmacy's Center for Medication Safety Advancement Indianapolis, Indiana

Medication Safety in Oncology: Role of the Technician

Courtney Yuen, Pharm.D., BCOP Oncology Pharmacy Manager UCSF Medical Center San Francisco, California

Pharmacy Technician's Role in Pediatric Medication Safety

Sheila Pedigo, Pharm.D., BCPS Pediatric Clinical Specialist Virginia Commonwealth University Medical Center Richmond, Virginia

Preventing Errors Associated with High-Alert Medications

Donna Horn, B.S.Pharm., D.Ph. Director, Patient Safety - Community Pharmacy Institute for Safe Medication Practices Horsham, Pennsylvania

The Joint Commission is Coming! What Do I Do?

Jeannell Mansur, Pharm.D., FASHP, FMSMO, CJCP Practice Leader, Medication Safety Joint Commission Resources Joint Commission International Oak Brook, Illinois

What is feedback report?

Feedback reports are the final step in a survey project and are critical for synthesizing the survey responses. Ideally, feedback should be provided broadly—to pharmacy management, chain and system patient safety officers and other senior managers, and pharmacy staff, either directly during meetings or through communication tools such as email, Intranet sites, or newsletters.

What happens if you use individual identifiers in surveys?

If you used individual identifiers on your surveys, after you close out data analysis and enter identification numbers in the electronic data file, destroy any information linking the identifiers to individual names. You want to eliminate the possibility of linking responses in the electronic file to individuals.

What is timeline in Figure 1?

Use the timeline in Figure 1 as a guideline in planning the tasks to be completed for a single pharmacy using a paper survey. Note the modifications we recommend if you plan to administer any surveys via the Web or are surveying multiple pharmacies.

What are the elements of an effective project?

Two of the most important elements of an effective project are a clear budget to determine the scope of your data collection effort and a realistic schedule. Think about your available resources:

What is the purpose of the survey chapter?

This chapter is designed to guide you through the planning and decisionmaking stages of your project.

What is the Community Pharmacy Survey?

The Community Pharmacy Survey on Patient Safety Culture emphasizes patient and medication safety and quality-assurance issues. The survey includes 36 items measuring 11 composites. In addition to the composites, the community pharmacy survey includes three items about the frequency of documenting different types of mistakes, three items about respondent background characteristics, an overall rating question, and a section for open-ended comments. The survey has a total of 43 items.

What is a pharmacy survey?

The survey is designed to be administered to all staff working in the pharmacy area where prescriptions are dropped off, filled, dispensed, and picked up or prepared for delivery. If your community pharmacy is located in a store that sells greeting cards or other household products, you should exclude staff who do not work in the pharmacy area of the store. All staff asked to complete the survey should have enough knowledge about your pharmacy and its operations to provide informed answers to the survey questions.

How to access PSLC?

To access in the PSLC, log into LaunchPad and search “PSLC” in the upper right corner search bar. Choose “PSLC Home” from the results list. Then click “Patient Safety Resources” from the left menu on the PSLC landing page. From the Resources page, click “Joint Patient Safety Reporting” under the Equip column.

What is the purpose of reporting patient safety events?

The reporting of all patient safety events, even those that don’t reach the patient, allows the DoD PSP to identify, analyze and learn from the sequence of events that may potentially lead to errors before they affect patients.

What is the DoD PSP?

The DoD PSP's Patient Safety Analysis Center, analyzes the reported data and additional data sources to provide cumulative data reports and feedback to the military treatment facilities through the services. These analyses are then used to design and develop programs and tools to assist the MTFs in reducing preventable harm and improve safety throughout the direct care system.

What is military direct care?

All Military Health System Direct Care Direct care refers to military hospitals and clinics , also known as “military treatment facilities” and “MTFs.” direct care facilities must report qualifying patient safety events to the DoD Patient Safety Program through Joint Patient Safety Reporting#N#Goes to the JPSR#N#. Self-reporting is one of the key components in the MHS’s effort to achieve high reliability, and continuously improve and provide the safest patient care possible. Events that are reported encompass all levels of severity and types of medical and dental care.

What is potential event?

Potential Events: Unsafe conditions that increase the likelihood of a patient safety event.

What order should videos be completed?

It is recommended the videos are completed in numerical order . A video knowledgebase completion checklist is also available. A link to this document is available above the first video link and in the “Resources” section below the videos.

Why is it important for pharmacists to work in the same environment?

If a pharmacist regularly works in the same environment, then he or she is able to see what processes need to change to ensure patient safety. Relationships between nursing and physicians would improve due to continuity of care. Nurses and pharmacists would report every single error, no matter how small.

Why is continuity of care important for pharmacists?

There would be continuity of care with work assignments. If pharmacists or nurses are changing hospitals every day, then they never really learn their patients. Processes could also vary from one hospital to another, which can lead to confusion for the clinician. If a pharmacist regularly works in the same environment, then he or she is able to see what processes need to change to ensure patient safety. Relationships between nursing and physicians would improve due to continuity of care.

What is a safety focus group?

A safety focus group would be set up where issues and processes are analyzed on a routine basis and changes are evaluated based on these analyses. This focus group in the pharmacy could report to a larger group in the hospital with each department represented if a particular issue affects other departments.

What are the most damaging messages a pharmacist can receive?

One of the most damaging messages a pharmacist can receive is leadership mishandling a medical error. If our leaders do not take the time to investigate the systems involved with the error and how the error happened, and instead rush to punitive action toward the clinician, then staff members will become more jaded and less involved.

What does a pharmacist do?

Pharmacists make sure that the correct medication is going to the correct patient. I signed up for this when I applied to pharmacy school in 1993.

What type of safety group should hospitals employ?

Hospitals should employ the same type of safety group that not only encompasses risk management, information technology, and nursing, but also includes actual clinicians who work with the systems and interact with patients and their orders.

What happens if a pharmacist is not in a separate room?

If the room isn’t separate, then there will be constant interruptions. Every interruption while pharmacists are in the middle of doing their job is a recipe for disaster, just as it is for a nurse on the floor. There would be continuity of care with work assignments.