Survey Form

Pharmacy Survey on Patient Safety Culture

This survey asks for your opinions about patient safety in this pharmacy and takes about 15 minutes to complete. Answer only about the pharmacy location/store where you received this survey.

Staff means EVERYONE who works in this pharmacy, including pharmacists, pharmacy technicians, pharmacy clerks, etc.

Patient safety is the prevention of patient harm resulting from the processes of health care delivery. In the pharmacy setting, it means that:

The right patient receives the right medication in the right dose at the right time by the right route, and
The patient or caregiver understands the purpose and proper use of the medication.

A mistake is any type of medication error, mistake, incident, or quality-related event, regardless of whether or not it reaches the patient or results in patient harm. Mistakes may be related to, or include:

Prescribing, transcribing, dispensing, administering, monitoring (use of medication), unsafe conditions or procedures in the pharmacy, etc.

If a question does not apply to you or you don’t know the answer, please answer “Does Not Apply or Don’t Know.”

Section A: Working in This Pharmacy

How much do you agree or disagree with the following statements?	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree	Does Not Apply or Don't Know
1. This pharmacy is well organized	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
2. Staff treat each other with respect	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
3. Technicians in this pharmacy receive the training they need to do their jobs	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
4. Staff in this pharmacy clearly understand their roles and responsibilities	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
5. This pharmacy is free of clutter	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
6. Staff in this pharmacy have the skills they need to do their jobs well	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
7. The physical layout of this pharmacy supports good workflow	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
8. Staff who are new to this pharmacy receive adequate orientation	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
9. Staff work together as an effective team	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
10. Staff get enough training from this pharmacy	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9

Section B: Communication and Work Pace

How often do the following statements apply to this pharmacy?	Never	Rarely	Sometimes	Most of the Time	Always	Does Not Apply or Don't Know
1. Staff ideas and suggestions are valued in this pharmacy	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
2. We encourage patients to talk to pharmacists about their medications	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
3. Staff take adequate breaks during their shifts	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
4. We have clear expectations about exchanging important prescription information across shifts	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
5. Staff feel comfortable asking questions when they are unsure about something	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
6. We have standard procedures for communicating prescription information across shifts	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
7. Our pharmacists spend enough time talking to patients about how to use their medications	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
8. Staff in this pharmacy discuss mistakes	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
9. We feel rushed when processing prescriptions	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
10. It is easy for staff to speak up to their supervisor/manager about patient safety concerns in this pharmacy	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
11. Our pharmacists tell patients important information about their new prescriptions	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
12. We have enough staff to handle the workload	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
13. When patient safety issues occur in this pharmacy, staff discuss them	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
14. The status of problematic prescriptions is well communicated across shifts	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
15. In this pharmacy, we talk about ways to prevent mistakes from happening again	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
16. Interruptions/distractions in this pharmacy (from phone calls, faxes, customers, etc.) make it difficult for staff to work accurately	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9

Section C: Patient Safety and Response to Mistakes

How much do you agree or disagree with the following statements?	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree	Does Not Apply or Don't Know
1. Staff are treated fairly when they make mistakes	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
2. When a mistake happens, we try to figure out what problems in the work process led to the mistake	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
3. This pharmacy places more emphasis on sales than on patient safety	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
4. This pharmacy helps staff learn from their mistakes rather than punishing them	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
5. When the same mistake keeps happening, we change the way we do things	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
6. This pharmacy is good at preventing mistakes	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
7. We look at staff actions and the way we do things to understand why mistakes happen in this pharmacy	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
8. Staff feel like their mistakes are held against them	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
9. The way we do things in this pharmacy reflects a strong focus on patient safety	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
10. Mistakes have led to positive changes in this pharmacy	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9

Section D: Documenting Mistakes

In this pharmacy, how often are the following types of mistakes documented (in writing OR tracked electronically)?	Never Documented	Rarely Documented	Sometimes Documented	Most of the Time documented	Always Documented	Does Not Apply or Don't Know
1. When a mistake reaches the patient and could cause harm but does not, how often is it documented?	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
2. When a mistake reaches the patient but has no potential to harm the patient, how often is it documented?	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9
3. When a mistake that could have harmed the patient is corrected BEFORE the medication leaves the pharmacy, how often is it documented?	___ 1	___ 2	___ 3	___ 4	___ 5	___ 9

Section E: Overall Rating

1. Think back on the survey topics and the definition of patient safety—dispensing the right medication accurately and making sure patients understand their medications and how to use them:

How do you rate this pharmacy on patient safety?

___ 1. Poor ___ 2. Fair ___ 3. Good ___ 4. Very Good ____ 5. Excellent

Section F: Background Questions

1. How long have you worked in this pharmacy?

___ a. Less than 6 months
___ b. 6 months to less than 1 year
___ c. 1 year to less than 3 years
___ d. 3 years to less than 6 years
___ e. 6 years to less than 12 years
___ f. 12 years or more

Typically, how many hours per week do you work in this pharmacy?

___ a. 1 to 16 hours per week
___ b. 17 to 31 hours per week
___ c. 32 to 40 hours per week
___ d. More than 40 hours per week

3. What is your position in this pharmacy? Check ONE category that best applies to your job.

___ a. Pharmacist (including pharmacy manager, lead pharmacist, pharmacist-in-charge, staff pharmacist)
___ b. Pharmacy technician (including lead technician and staff technician)
___ c. Pharmacy clerk or pharmacy cashier
___ d. Pharmacy student intern/extern
___ e. Other (Please write your job title): ___________________________________

Section G: Your Comments

Please feel free to write any comments about how things are done or could be done in your pharmacy that might affect patient safety.

Current as of September 2012

Internet Citation: Survey Form: Pharmacy Survey on Patient Safety Culture. September 2012. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/pharmacy/toolkit/PharmSOPSform.html