1. No category

Patient Safety Culture within the University of Utah Health Care
Community Pharmacies
Eve Van Wagoner, PharmD1,2; Casey Tak, MPH, PhD Candidate1,3; Krystal Moorman, PharmD, BCPS1,2;
Brandon T. Jennings, PharmD, BCACP1,2; Vanessa Stevens, PhD1,3; Nancy A. Nickman, PhD, RPh1,3
1University
of Utah College of Pharmacy, Salt Lake City, Utah; 2University of Utah Hospitals and Clinics, Salt Lake City, Utah; 3University of Utah Pharmacotherapy Outcomes Research Center, Salt Lake City, Utah
Highlighted Results
Introduction / Background
•  High-risk industries (aviation and nuclear energy) assess safety by
monitoring injuries and deaths1
•  The health care industry focuses on patient health and outcomes1,2,3
•  Organizational patient safety culture should be measured to determine if
employees focus on fixing errors rather than blaming individuals3
•  A pharmacy’s patient safety culture can impact chances that medication
errors will be reported to management, prompting modifications in policies4
Pharmacy 4 – Pharmacists, interns, technicians and clerks
Pharmacy Sampling
UUHC Outpatient Pharmacies (N=14)
Overall Perception of
Patient
Safety
11.5%
Response to Mistakes
15.3%
11.5 %
Objective
•  Evaluate employee perceptions of patient safety culture in University of Utah
Health Care (UUHC) outpatient pharmacies, using the validated Agency for
Healthcare Research and Quality (AHRQ) “Community Pharmacy Survey on
Patient Safety Culture” 5
Methods / Process
0% 20% 40% 60% 80% 100% 0% 20% 40% 60% 80% 19.2%
100% 29.4%
Pharmacy 8 – Pharmacists, interns, technicians, and clerks
29.5 %
Overall Perception of
Patient Safety
Response to Mistakes
Composites
Patient Counseling
Communication Openness
Pharmacies with > 5 employee responses
(N= 7)
Pharmacies w/ > 5
tech, intern, and
clerk responses
(N= 1)
Pharmacies w/ > 5
pharmacist
responses
(N= 1)
Response Rates
Pharmacists 56%
Interns 13%
System-wide
49%
Overall Perceptions of Patient Safety
Organizational Learning – Continuous
Improvement
Teamwork
Communication across Shifts
Communication about Mistakes
Responses to Mistakes
0% 20% 40% 60% 80% 100% System-wide Pharmacists
0% Physical Space and Environment
Clerks 33%
Staffing, Work Pressure & Space
Communication about
Mistakes
0% Correspondence
Please address inquiries to:
Eve Van Wagoner, PharmD
PGY1 Community Practice Resident
University of Utah College of Pharmacy/ South Jordan Health Center
Eve.VanWagoner@pharm.utah.edu
All authors have no relevant conflicts of interest to declare
20% 40% 60% 80% Never/ Rarely
Strongly Disagree/ Disagree
40% 60% 80% 100% System-wide Technicians
Communication about
Mistakes
Staff Training and Skills
Technicians 36%
20% 100% 0% 20% 40% 60% 80% Always/ Most of the Time
Strongly Agree/ Agree
•  Quality improvement (QI) initiative using a convenience sample of UUHC
outpatient pharmacy employees (pharmacists, technicians, interns, clerks)
•  A secure electronic AHRQ Community Pharmacy Survey on Patient Safety
Culture was administered via Qualtrics
•  Analytic procedures outlined in the AHRQ Survey Guide were followed,
including lack of detailed analysis below the pharmacy level aggregate if
there were fewer than 5 respondents per pharmacy or fewer than 5
respondents per specific job category, per pharmacy
100% Limitations
•  Only one pharmacy’s responses allowed for analysis by job type
•  Seven of 14 pharmacies included sufficient employee responses for analysis
•  Surveys offer qualitative rather than quantitative measurements
Conclusions
•  System-wide community pharmacy employees reported that mistakes that
reach the patient are reported most of the time, but mistakes that are
corrected BEFORE leaving the pharmacy are rarely/never documented
•  Results varied by pharmacy location, pharmacy size, and job type
•  Five system-wide composites rated positively less than 75% of the time:
Communication across Shifts
Physical Space and Environment
Communication about Mistakes
Staffing, Work Pressure & Space
Staff Training and Skills
References
1.  Colla JB, Bracken AC, Kinney LM, et al. Measuring patient safety climate: a review of surveys.
Qual Saf Health Care. 2005;14:364-366. Nieva VF, Sorra. Safety culture assessment
2.  Nieva VF, Sorra J. Safety culture assessment: a tool for improving patient safety in healthcare
organisations. Qual Saf Health Care. 2003;12(Suppl 2):ii17-ii23.
3.  Institute of Medicine. Safety Culture Assessment: A tool for improving patient safety in health
care organizations. Washington DC: National Academy Press, 2001.
4.  Ashcroft DM, Morecroft C, Parker D, et al. Safety culture assessment in community pharmacy:
development, face validity and feasibility of the Manchester Patient Safety Assessment
Framework. Qual Saf Health Care. 2005;14:417-421.
5.  Franklin M, Sorra J. Community Pharmacy Survey on Patient Safety Culture: User’s Guide.
Rockville, MD: Agency for Healthcare Research and Quality; October 2012; updated April
2014.