report pharmacy patient safety

Since 2005, pharmacy contractors have been required to record patient safety incidents in an incident log and report these to the National Reporting and Learning Service (NRLS).

Full Answer

What are patient safety incidents in 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 are encouraged to report incidents , whether they result in harm or not.

How can the pharmacist support patient safety outcomes?

Articles highlighted several ways the existing roles and responsibilities of the pharmacist could be expanded to support patient safety outcomes. For example, community pharmacists have historically provided patients counseling services and communication regarding potentially unsafe medication combinations.

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.

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 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.

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 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.

Can a pharmacist be liable for pharmacy mistakes?

When pharmacy errors lead to harm, the patient may have the right to bring a pharmacy error lawsuit seeking compensation. Pharmacists may liable for malpractice if they dispense the wrong drug, the incorrect dosage or fail to recognize a contraindication with other medicines the patient is taking.

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...•

Why reporting is necessary for patient safety?

Reporting systems (frequently referred to as reporting and learning systems) capture patient safety concerns, hazards and/or incidents and are meant to trigger action, facilitate communication, response, learning and improvement.

Why is it important to report patient safety incidents?

The reporting of incidents to a national central system helps protect patients from avoidable harm by increasing opportunities to learn from mistakes and where things go wrong.

Why is patient reporting important?

Patient-reported outcomes provide information on the patient experience and can be the target of therapeutic intervention.

What to do if a pharmacist makes a mistake?

If you were given the wrong medication from a pharmacy or drug store, and you have not yet taken the medication, it is good that you caught the mistake. You call the pharmacy immediately, advise them of the mistake and pick up the correct prescription.

What do you do in your pharmacy when an error is made?

You should be open and honest with the patient — apologise and explain what went wrong. You should record the mistake and ensure that it is reported appropriately within the organisation. For example, notifying the superintendent pharmacist.

What is liability in pharmacy?

Pharmacist professional liability insurance is coverage designed to protect pharmacists when a patient claims an actual or alleged error or omission within the scope of your practice. No pharmacist acts with the intent to harm patients.

What is a medication error?

Medication error is a broad term used to describe a number of more specific events that may cause, or lead to, inappropriate medication use or patient harm.[3] . These include patient receipt of the incorrect prescription (e.g., receiving the wrong drug or the correct drug but at the wrong dosage), harmful drug-to-drug interactions, ...

Why is pharmacist review important?

However, pharmacist review and approval of prescriptions before nurses can access a medicine is critical to ensuring the correct medications are dispensed. With the growth of electronic health records, pharmacist review can be done remotely, minimizing burden, and is an important fail-safe in these systems.

How has technology improved pharmacists?

Technological advances have increased opportunities for pharmacists to be involved in changing the patient safety paradigm. A review made available on PSNet at the beginning of 2019 captured some of the key technology advances in this space. For example, the use of some technologies, such as robotics for medication dispensing, can reduce errors and allow pharmacists to spend more time on medication therapy management activities. As pharmacists increasingly take on new roles and responsibilities, the need to optimize machine learning and clinical decision support systems to create efficiencies and supplement the pharmacist becomes more acute. As a critical user of these resources, pharmacists can be instrumental in implementation planning and evaluation to ensure systems are used most effectively.

Why do pharmacists use technology?

Use of Pharmacists to Address Limitations of Technology. While some technology has enabled pharmacists to expand their roles and has improved aspects of medication safety, pharmacists have also had to learn to work with the limitations of technology to address new risks to patient safety. Several articles published on PSNet in 2019 noted examples ...

What is a culture of safety?

A marker of a culture of safety is a blame-free environment where individuals are able to report errors or near misses without fear of reprimand or punishment. This type of feedback process is an essential component of ensuring patient safety in clinical care,[5] and learning from errors can help to reduce future mistakes.[6] Pharmacists have a unique expertise and knowledge base that can support improvements in medication error rates and play a critical role in the reporting process, such as providing appropriate feedback to providers. This may result in improved prescribing practices and greater team-work as well as improving pharmacist confidence and feeling of self-worth in the care team.

What is the role of social determinants in patient care?

Playing a greater role in improving care transitions and considering non-clinical patient factors, such as social determinants of health, all support a transition to longitudinal patient care and can serve to enhance pharmacist patient safety services.

How effective is antibiotic stewardship?

Antibiotic stewardship programs have been proven effective at improving clinical outcomes, reducing adverse events, and reducing antibiotic resistance. [7],[8],[9],[10] Given the success of the antibiotic stewardship model, pharmacist leadership in other medication stewardship programs may increase. As already discussed, pharmacists offer a unique skillset to advance pain and opioid stewardship programs. Other therapeutic areas, such as glycemic control and thrombotics, may also be suitable targets for future programs. As evidence continues to demonstrate the success of stewardship programs, medication stewardship could become a central aspect of the pharmacists’ role in ensuring patient safety.

Why do patients have prior issues with medication adherence?

In many instances, a patient may have prior issues with medication adherence because they experienced side effects, were not receiving a clinical benefit or had issues with cost for the therapy. Pharmacists counseling to improve adherence therefore should always consider these key elements.

What is the role of pharmacists in healthcare?

Pharmacists and Patient Safety. As the most accessible health care professionals, pharmacists are the “guardians” of safe and effective medication use . States are considering expanding the scope of practice for pharmacists and even recognizing pharmacists as providers!

What is the ultimate resource when it comes to managing and adjusting a medication action plan?

While physicians and other health care professionals may have extensive training on diagnosis and treatment plans, the pharmacists are the ultimate resource when it comes to managing and adjusting a medication action plan.

Do pharmacists have a role in medication dispensing?

Pharmacists will always have a role in the process of medication dispensing. But, to fully recognize the role and benefit of the pharmacist we must move towards recognition of pharmacist services that can be separate and distinct from the dispensing of a medication.

Valproate

The high risks associated with valproate exposure during pregnancy remains a high priority patient safety concern.

MHRA Yellow card reporting

The MHRA dedicated site for reporting suspected problem or incidence to medicines and medical devices.

MHRA COVID-19 Yellow Card reporting

The MHRA dedicated site for healthcare professionals, patients and carers are asked to report all suspected side effects to medicines or medical device adverse incidents related to COVID-19 treatment, including COVID-19 vaccines.

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.

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.

Why do pharmacy staff 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 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.

Why is it important to report errors?

Error reporting is essential to a healthy safety culture. Error reporting can help health care providers learn about potential risks, actual errors, causes of errors, and ways to prevent errors and patient harm.

What happens if a patient's error report is too long?

If the reporting form is too long, people will not want to take the time to complete it. Along with health system leadership, acknowledge and reward those who submit error reports as they are playing a positive role in patient 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 purpose of the Community Pharmacy Survey on Patient Safety Culture?

The purpose of the Community Pharmacy Survey on Patient Safety Culture is to measure the culture of patient safety in a single pharmacy location. A pharmacy chain or health care system may have multiple pharmacies or multiple stores in different locations, but each unique location would be considered a separate pharmacy for the purposes of the survey and for feedback.

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.

What is safety culture?

The safety culture of an organization is the product of individual and group values, attitudes, perceptions, competencies, and patterns of behavior that determine the commitment to, and the style and proficiency of, an organization’s health and safety management. Organizations with a positive safety culture are characterized by communications founded on mutual trust, by shared perceptions of the importance of safety, and by confidence in the efficacy of preventive measures.

Can you include a pharmacy identifier in a survey?

You can include a pharmacy identifier as part of the password that is used to access the survey. The password would be linked to a particular pharmacy site. Alternatively, you can use a customized hyperlink for staff within a pharmacy site that differs across sites.

Can you conduct a patient safety survey anonymously?

Staff completing patient safety culture surveys are usually concerned about the confidentiality of their responses, so we recommend that you conduct an individually anonymous survey. This means you should not use identifiers to track individuals. Also, do not ask respondents to provide their names on completed survey forms. Understand that confidentiality concerns are even stronger in smaller pharmacies. You need to ensure that respondents feel comfortable reporting their true perceptions and confident that their answers cannot be traced back to them.

Should you publicize a survey before or after data collection?

As with paper surveys, we strongly recommend publicizing the survey before and during data collection. Be sure to advertise that the survey is supported by pharmacy, chain, or system leaders. Publicity activities may include:

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 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.

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.

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 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.

Background: The Evolving Role of The Pharmacist

Expanding Pharmacist Care Services to Support Patient Safety

Use of Pharmacists to Address Limitations of Technology

Pharmacists' Role in Error Reporting and Feedback

• A marker of a culture of safety is a blame-free environment where individuals are able to report errors or near misses without fear of reprimand or punishment. This type of feedback process is an essential component of ensuring patient safety in clinical care,and learning from errors can help to reduce future mistakes.Pharmacists have a unique expe...

See more on psnet.ahrq.gov