Improving Patient Safety in Community Pharmacies: A Resource List

Resources by Dimension

The following resources are organized according to the relevant Community Pharmacy Survey on Patient Safety Culture dimensions they can help improve. Some resources are duplicated and cross-referenced because they may apply to more than one dimension.

Dimension 1. Physical Space and Environment

  1. Improvement Report: Lean Thinking Applied to Pharmacy Processes
    http://www.ihi.org/resources/Pages/ImprovementStories/MemberReportLeanThinkingAppliedtoPharmacyProcesses.aspx

    This improvement report on the Institute for Healthcare Improvement Web site identifies changes made to the physical space in the pharmacy department and the implementation of Lean Thinking methodology and tools to reduce turnaround time for medications and decrease errors.

  2. Institute for Safe Medication Practices (ISMP) Medication Safety Self Assessment® for Community/Ambulatory Pharmacy
    http://www.ismp.org/Survey/NewMssacap/Index.asp

    This self-assessment is a comprehensive tool designed to help health care providers and their staff assess the safety of medication practices in their pharmacy, identify opportunities for improvement, and compare their experience with the aggregate experiences of demographically similar community pharmacies around the Nation. It is divided into the following 10 elements:

    • Patient information.
    • Drug information.
    • Communication of drug orders and other drug information.
    • Drug labeling, packaging, and nomenclature.
    • Drug standardization, storage, and distribution.
    • Use of devices.
    • Environmental factors.
    • Staff competency and education.
    • Patient education.
    • Quality process and risk management.
  3. Using Change Concepts for Improvement
    http://www.ihi.org/resources/Pages/Changes/UsingChangeConceptsforImprovement.aspx

    A change concept is a general notion or approach to change that has been found to be useful in developing specific ideas for changes that lead to improvement. This Institute for Healthcare Improvement Web page outlines change concepts such as error proofing, optimizing inventory, and improving workflow. 

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Dimension 2. Teamwork

  1. Patient Safety Primer: Teamwork Training
    http://psnet.ahrq.gov/primer.aspx?primerID=8

    Providing safe health care depends on highly trained individuals with disparate roles and responsibilities acting together in the best interests of the patient. The AHRQ Patient Safety Primer explains this topic further and provides links for more information on what is new in teamwork training.

  2. Patient Safety Through Teamwork and Communication Toolkit
    http://www.safecoms.org/ImplementationToolkit/tabid/567/Default.aspx

    This toolkit consists of an education guide and communication tools. The education guide provides a plan for education and integration of communication and teamwork factors into clinical practice. The communication tools describes each of the following tools and provisions for implementation:

    • Multidisciplinary Rounding.
    • Huddles.
    • Rapid Response and Escalation.
    • Structured Communication.
  3. TeamSTEPPS®—Team Strategies and Tools to Enhance Performance and Patient Safety
    http://www.ahrq.gov/professionals/education/curriculum-tools/teamstepps/index.html

    Developed jointly by the Department of Defense (DoD) and AHRQ, TeamSTEPPS is a resource for training health care providers in better teamwork practices. The training package capitalizes on DoD's years of experience in medical and nonmedical team performance and AHRQ's extensive research in the fields of patient safety and health care quality. Following extensive field testing in the Military Health System and several civilian organizations, a multimedia TeamSTEPPS toolkit is now available in the public domain to civilian health care facilities and medical practices. Additional TeamSTEPPS tools are in development.

  4. TeamSTEPPS® Readiness Assessment Tool
    http://teamstepps.ahrq.gov/readiness/

    Answering these questions can help an institution understand its level of readiness to initiate the TeamSTEPPS program. Staff may find it helpful to have a colleague review responses or to answer the questions with a larger group (e.g., senior leaders).

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Dimension 3. Staff Training and Skills

  1. AHRQ Patient Safety Education and Training Catalog
    http://psnet.ahrq.gov/pset/index.aspx

    The AHRQ Patient Safety Education and Training Catalog consists of more than 300 patient safety programs currently available in the United States. The catalog offers an easily navigable database of patient safety education and training programs consisting of a robust collection of information each tagged for easy searching and browsing. The new database identifies a number of characteristics of the programs, including clinical area, program and learning objectives, evaluation measures, and cost.  The clinical areas in the database align with the PSNet Collections.

  2. Strategies To Improve Communication Between Pharmacy Staff and Patients: Training Program for Pharmacy Staff
    http://www.ahrq.gov/professionals/quality-patient-safety/pharmhealthlit/pharmlit/pharmtrain.html

    This training program is designed to introduce pharmacists to the problem of low health literacy in patient populations and to identify the implications of this problem for the delivery of health care services. The program also explains techniques that pharmacy staff members can use to improve communication with patients who may have limited health literacy skills.

  3. Tobacco Cessation Counseling: A Protocol for Practicing Pharmacists 
    http://media.ashp.org/tobacco/
    (multimedia file; may not be accessible to users with disabilities)

    This slide show is a cessation intervention course that pharmacists and clinicians can take and earn free continuing education credit.The objectives of this course are:

    • Describe a new, redefined role for the pharmacist in the tobacco cessation process, positioning them as the initiator of the quit not solely as the provider of services.
    • Summarize how the pharmacist can serve as a motivator and educator for cessation.
    • Explain the importance of pharmacists referring all patients to appropriate intensive interventions after initiating the cessation process.
  4. Working Together to Manage Diabetes: A Guide for Pharmacy, Podiatry, Optometry, and Dental Professionals
    http://wellnessproposals.com/health-care/handouts/diabetes/diabetes-pharmacists-podiatrists-optometrists-dentists.pdf

    Working Together to Manage Diabetes is a cross-training document developed by the National Diabetes Education Program's Pharmacy, Podiatry, Optometry, and Dental Professionals' Work Group. The goal is to reinforce consistent diabetes messages across the four disciplines of pharmacy, podiatry, optometry, and dentistry, and to promote a team approach to comprehensive diabetes care that encourages collaboration among all care providers.

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Dimension 4. Communication Openness

  1. SBAR Technique for Communication: A Situational Briefing Model
    http://www.ihi.org/knowledge/Pages/Tools/SBARTechniqueforCommunicationASituationalBriefingModel.aspx

    The SBAR technique provides a framework for communication between members of the health care team about a patient's condition. This tool from IHI has two documents. The first, "SBAR Report to Physician About a Critical Situation," is a worksheet/script a provider can use to prepare to communicate with a physician about a critically ill patient. The second, "Guidelines for Communicating With Physicians Using the SBAR Process," details how to carry out the SBAR technique.

Cross-references to resource already described:

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Dimension 5. Patient Counseling

  1. AHRQ Pharmacy Health Literacy Center
    http://www.ahrq.gov/professionals/quality-patient-safety/pharmhealthlit/index.html

    AHRQ Pharmacy Health Literacy Center provides pharmacists with recently released health literacy tools, curricular modules for pharmacy faculty, and resources for pharmacists interested in understanding more about health literacy. 

  2. Implementing MTM in your Practice 
    http://www.pharmacist.com/implementing-mtm-your-practice

    The American Pharmacists Association outlines resources to support medication therapy management (MTM) services, including getting your MTM business started and inspiration and ideas from colleagues.    

  3. Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation 
    http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/match/

    This AHRQ toolkit provides a step-by-step guide to improving the medication reconciliation process and includes guidelines, flowcharts, modifiable templates,  and lessons learned.

  4. National Council on Patient Information and Education
    http://talkaboutrx.org

    The National Council on Patient Information and Education Web site features educational resources and programs designed to stimulate and improve communication of information on the appropriate use of medicines to consumers and health care professionals.

  5. Patient Outreach Tools 
    http://www.pharmacist.com/tools-patient-outreach

    The American Pharmacists Association  features a number of patient outreach tools that include information on national campaigns and initiatives to help pharmacies educate patients on important topics such as disposal of medications, poison control, diabetes, and physical activity.

  6. Pharmacists Support Employees and Physicians in Managing Chronic Conditions, Leading to Better Care and Disease Control, Lower Costs, and Higher Productivity
    http://www.innovations.ahrq.gov/content.aspx?id=3380

    Using a model known as medication therapy management, which is often sponsored by employers, a program manager assigns participants to care managers (typically pharmacists) to provide ongoing chronic care management support to employees/covered dependents and their physicians. The goal is to improve care processes and patient self-management skills related to diabetes, asthma, cardiovascular risk factors, and depression. Sponsoring employers create financial incentives for participation, typically through lower or waived copayments for drugs and supplies or reductions in the employee share of the premium. Care managers meet regularly with individual enrollees to support their self-management and contact their physician as needed to suggest treatment changes. Originally pioneered in Asheville, North Carolina, for city employees (and hence known as the Asheville Project) and now implemented by employers throughout the Nation, the program has improved adherence to recommended care and self-management behaviors, leading to better disease control, lower costs, higher productivity, and a significant return on investment.

  7. The PROTECT Initiative: Advancing Children's Medication Safety
    http://www.cdc.gov/medicationsafety/protect/protect_initiative.html

    The PROTECT Initiative is an innovative collaboration bringing together public health agencies, private sector companies, professional organizations, consumer/patient advocates, and academic experts to develop strategies to keep children safe from unintentional medication overdoses.  Medication overdoses can lead to harm, sometimes requiring emergency treatment or hospitalization and are a significant public health problem. Over-the-counter and prescription medications are commonly used for people of all ages. This frequency of use increases the potential for unintentional overdoses. Children are especially vulnerable to unintentional overdoses, most of which can be prevented.

  8. Team Up. Pressure Down. 
    http://millionhearts.hhs.gov/resources/teamuppressuredown.html

    Team Up. Pressure Down is a nationwide program to lower blood pressure and prevent hypertension through patient-pharmacist engagement. The videos and resources on this page can help patients, pharmacists, and health care providers better understand high blood pressure and the steps they can take to prevent or treat it. Team Up. Pressure Down was developed through the Million Hearts® Initiative sponsored by the U.S. Department of Health and Human Services.

  9. With Support From Web-Based Tools, Pharmacists Help Individuals Adopt Healthier Behaviors, Reduce Cardiovascular Risk
    http://www.innovations.ahrq.gov/content.aspx?id=3182

    This featured profile is available on AHRQ's Health Care Innovations Exchange Web site. Under a program known as HealthyHeartClub.com, pharmacists work with individuals with or at risk for heart disease, educating them on ways to reduce cardiovascular risk and helping them set and reach goals related to health outcomes and health-related behaviors, including diet, physical activity, and medication adherence. Designed to support primary care providers' work with patients, the program consists of pharmacists conducting an initial in person consultation, weekly check-ins via Email, and monthly group classes, supported by a patient-friendly Web site that provides easy-to-understand information and tools to track progress toward established goals.

Cross-reference to resources already described:

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Dimension 6. Staffing, Work Pressure, and Pace

  1. Beating Behind-the-Counter Job Stress
    http://www.pharmacytimes.com/publications/issue/2010/October2010/BeatingJobStress-1010  

    Heavy workloads and long hours make stress management a critical skill for pharmacists.  With a basic knowledge of coping strategies, pharmacists can overcome stress to achieve their personal best. This feature in Pharmacy Times defines stress in the pharmacy and identifies possible solutions for handling the stress.

  2. Deflect Distractions and Intercept Interruptions
    http://www.pharmacist.com/node/206033

    This Institute for Safe Medication Practices error alert focuses on interruptions and distractions. The American Pharmacists Association discusses the effects of interruptions and distractions, their sources, and strategies to help decrease distractions..

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Dimension 7. Communication About Prescriptions Across Shifts

Cross-reference to resource already described:

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Dimension 8. Communication About Mistakes

  1. Provide Feedback to Frontline Staff
    http://www.ihi.org/resources/Pages/Changes/ProvideFeedbacktoFrontLineStaff.aspx

    Feedback to frontline staff is critical in demonstrating a commitment to safety and ensuring that staff members continue to report safety issues. This Institute for Healthcare Improvement Web page identifies tips and tools for communicating feedback.

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Dimension 9. Response to Mistakes

  1. Call to Action: Safeguarding the Integrity of Healthcare Quality and Safety Systems
    http://www.nahq.org/uploads/NAHQ_call_to_action_FINAL.pdf

    The National Association for Healthcare Quality Call to Action: Safeguarding the Integrity of Healthcare Quality and Safety Systems, provides best practices to enhance quality, improve ongoing safety reporting and protect staff. It addresses accountability, protection of those who report quality and safety concerns, and accurate reporting and response.

  2. Decision Tree for Unsafe Acts Culpability
    http://www.ihi.org/resources/Pages/Tools/DecisionTreeforUnsafeActsCulpability.aspx

    The decision tree for unsafe acts culpability is a tool available for download from the Institute for Healthcare Improvement Web site. Staff can use this decision tree when analyzing an error or adverse event in an organization to help identify how human factors and system issues contributed to the event. This decision tree is particularly helpful when working toward a nonpunitive approach in an organization.

  3. Patient Safety and the "Just Culture"
    http://www.health.ny.gov/professionals/patients/patient_safety/conference/2007/docs/patient_safety_and_the_just_culture.pdf

    This presentation by David Marx defines just culture, the safety task, the just culture model, and statewide initiatives in New York.

  4. Patient Safety and the "Just Culture": A Primer for Health Care Executives
    http://psnet.ahrq.gov/resource.aspx?resourceID=1582

    Accountability is a concept that many leaders wrestle with as they steer their organizations and patients toward understanding and accepting the idea of a blameless culture within the context of medical injury. This report by David Marx is available for download through the AHRQ Patient Safety Network and outlines the complex nature of deciding how best to hold individuals accountable for mistakes.

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Dimension 10. Organizational Learning—Continuous Improvement

  1. AHRQ Health Care Innovations Exchange Learn & Network
    http://www.innovations.ahrq.gov/learn_network.aspx

    This part of the Health Care Innovations Exchange Web site has information on how to introduce innovations to an organization and how to encourage others to think "outside the box" and accept new ideas. Learn & Network has tools and resources on specific topics such as community care coordination and building relationships between clinical practices and the community to improve care.

  2. High-Alert Medication Modeling and Error-Reduction Scorecards (HAMMERS) for Community Pharmacies
    http://psnet.ahrq.gov/resource.aspx?resourceID=26381

    This free toolkit was developed to help community pharmacies identify risk factors within the dispensing process, provide estimates of the impact of each risk factor, estimate how often an error or adverse drug event reaches a patient, assess how these risks may affect patients, and implement strategies to prevent errors. By using this tool, pharmacists can estimate how often prescribing and dispensing errors reach patients and how the frequency will change if certain interventions are implemented.

  3.  Improving Medication Safety in Community Pharmacy: Assessing Risk and Opportunities for Change
    http://www.ismp.org/communityRx/aroc/ (requires Email address for access)

    This manual is designed to help community pharmacy personnel identify potential medication safety risks and prevent errors. Pharmacists can use the materials and tools in this manual to pinpoint specific areas of weakness in their medication delivery systems and to provide a starting point for successful organizational improvements.

    The goals of this manual are to:

    • Raise awareness of error-prone processes in the medication delivery system.
    • Build awareness of risk-identification opportunities in the community pharmacy setting.
    • Maximize the appropriate application of system strategies to reduce organizational risk.
  4. Institute for Healthcare Improvement: Plan-Do-Study-Act (PDSA) Worksheet
    http://www.ihi.org/resources/Pages/Tools/PlanDoStudyActWorksheet.aspx

    The Plan-Do-Study-Act (PDSA) Worksheet is a useful tool for documenting a test of change. The PDSA cycle is shorthand for testing a change by developing a plan to test the change (Plan), carrying out the test (Do), observing and learning from the results (Study), and determining needed modifications (Act).

  5. Institute for Healthcare Improvement: Tools  
    http://www.ihi.org/resources/Pages/Tools/default.aspx

    The IHI Web site features tools to help organizations accelerate improvement. Users can search for tools related to particular topics using the "My Filters" button. For example, pharmacies might be interested in filtering results by pharmacist in the role/profession field or by medication safety in topics. 

  6. Mistake Proofing the Design of Health Care Processes
    http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/mistakeproof/index.html

    This resource is a synthesis of practical examples from the real world of health care on the use of process or design features to prevent medical errors or the negative impact of errors. It contains more than 150 examples of mistake proofing that can be applied in health care, in many cases relatively inexpensively. By using this resource, risk managers and chief medical officers can benefit from commonsense approaches to reducing risk and litigation. In addition, organizations can find the groundwork for a successful program that fosters innovation and creativity as they address their patient safety concerns and approaches.

  7.  Patient Safety Primer: Root Cause Analysis
    http://psnet.ahrq.gov/primer.aspx?primerID=10

    Root cause analysis (RCA) is a structured method used to analyze adverse events. Initially developed to analyze industrial accidents, RCA is now widely deployed as an error analysis tool in health care. The AHRQ Patient Safety Network explains this topic further and provides links for more information on what is new in RCA.

  8. Will It Work Here?: A Decisionmaker's Guide to Adopting Innovations
    http://www.innovations.ahrq.gov/guide/guideTOC.aspx

    The goal of this guide is to promote evidence-based decisionmaking and help decisionmakers determine whether an innovation would be a good fit or an appropriate stretch for their health care organization.

Cross-reference to resources already described:

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Dimension 11. Overall Perceptions of Patient Safety

  1. Basic Patient Safety Program Resource Guide for "Getting Started"
    https://www.premierinc.com/quality-safety/tools-services/safety/topics/patient_safety/program_tools.jsp

    This resource guide has tools to help health care facilities implement a patient safety program. The program tools, all of which may be customized as needed, include:

    • Generic safety plan: template.
    • Comprehensive medical safety program.
    • Quality and safety officer job description: template.
    • Organized assignments for accompanying patient safety plan or program.
    • American Society for Healthcare Risk Management: perspective on disclosure of information on unanticipated outcomes.
    • Checklist for patient safety and The Joint Commission on the Accreditation of Healthcare Organizations standards.
  2. Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices
    http://www.ahrq.gov/research/findings/evidence-based-reports/ptsafetyuptp.html

    This AHRQ evidence report updates the 2001 report, Making Health Care Safer: A Critical Analysis of Patient Safety Practices. The goal of this project was to review important patient safety practices for evidence of effectiveness, implementation, and adoption. For example, it discusses the use of clinical pharmacists to prevent adverse drug events. 

  3. Patient Safety Primer: Safety Culture
    http://psnet.ahrq.gov/primer.aspx?primerID=5

    The concept of safety culture originated outside health care, in studies of high-reliability organizations. These organizations consistently minimize adverse events despite carrying out intrinsically complex and hazardous work. High-reliability organizations maintain a commitment to safety at all levels, from frontline providers to managers and executives. This commitment establishes a "culture of safety." The AHRQ Patient Safety Network explains this topic further and provides links for more information on what is new in safety culture.

  4. Studer Group Toolkit: Patient Safety
    http://www.sgna.org/Portals/0/Events/Annual%20Course/2013%20-%20Austin/Karen%20Cook/Toolkit.Patient%20Safety.pdf

    This toolkit provides health care leaders and frontline staff with specific tactics they can immediately put into action to improve patient safety outcomes. By routinizing specific behaviors, organizations can improve patient safety without purchasing new equipment, adding staff, or spending additional time to put them into practice. The actions are divided into eight sections, each of which has been identified as a priority area for health care organizations to address as they seek to provide safer care.

Cross-reference to resources already described:

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Current as of April 2014
Internet Citation: Improving Patient Safety in Community Pharmacies: A Resource List : Resources by Dimension. April 2014. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/pharmacy/resource_list/resource_list2.html