Chapter 1. Introduction

Pharmacy Survey User's Guide

As pharmacies continually strive to improve safety and quality, there is growing recognition of the importance of establishing a culture of patient safety. Achieving such a culture requires an understanding of the values, beliefs, and norms about what is important in the organization and what attitudes and behaviors related to patient safety are expected and appropriate. A definition of safety culture applicable to all health care settings is provided below.

Safety Culture Definition

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. 

Source: Study Group on Human Factors. Organising for safety: third report of the ACSNI (Advisory Committee on the Safety of Nuclear Installations). Sudbury, UK: HSE Books; 1993.

Development of the Pharmacy Survey on Patient Safety Culture

Purpose

In November 2004, the Agency for Healthcare Research and Quality (AHRQ) released the Hospital Survey on Patient Safety Culture (HSOPS). The hospital survey has been well received and administered in more than 1,000 hospitals. Subsequently, AHRQ released the Nursing Home Survey on Patient Safety Culture in 2008 and the Medical Office Survey on Patient Safety Culture in 2009. In response to interest in a survey that focuses on patient safety culture in community pharmacies, AHRQ sponsored the development of the Pharmacy Survey on Patient Safety Culture.

The new survey is designed specifically for pharmacy staff and asks for their opinions about the culture of patient safety in their pharmacies. The survey can be used to:

  • Raise staff awareness about patient and medication safety.
  • Assess the current status of patient safety culture.
  • Identify strengths and areas for patient safety culture improvement.
  • Examine trends in patient safety culture change over time.
  • Evaluate the cultural impact of patient safety initiatives and interventions.
  • Conduct internal and external comparisons.

Survey Development and Pilot Test

Researchers on the survey design team conducted the following activities to identify key dimensions of pharmacy safety culture, relevant background questions about staff and pharmacy characteristics, and appropriate terms and words to use in the survey:

  • Reviewed the literature, including existing surveys, pertaining to patient safety, medication safety, pharmacy errors and quality-related events, error reporting, safety climate and culture, and organizational climate and culture.
  • Conducted background interviews with experts in the field of pharmacy practice and patient safety and with pharmacy staff, including pharmacists, pharmacy technicians, and pharmacy clerks.

The design team developed draft survey items to measure key dimensions and background characteristics and conducted cognitive interviews with pharmacy staff. Interview participants included pharmacy managers, staff pharmacists, pharmacy interns, and technicians. The design team also received input from a 19-member technical expert panel (TEP). TEP members represented AHRQ, professional associations, universities, and pharmacy chains.

The draft survey was pilot tested in 62 pharmacies across 25 States. Participating pharmacies varied by number of staff and community pharmacy type (independent, supermarket, mass merchant/discount retailer, traditional drugstore, and integrated health system). All eligible staff within each pharmacy were asked to complete the survey.

Analysts examined the reliability and factor structure of the patient safety culture dimensions or composites. Based on these analyses, as well as input from AHRQ and the TEP, the final items and composites in the Pharmacy Survey on Patient Safety Culture were determined to have sound psychometric properties (Sorra, Franklin, et al., 2012). 

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Pharmacy Definition

The purpose of the 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.

This definition is essential because the survey is designed to measure patient safety culture in a single pharmacy site. You may, of course, choose to administer the survey to multiple sites in your chain or health care system. If so, each pharmacy has to be identified as a separate site rather than being surveyed as one entity that includes all chain or system pharmacy sites.

The survey was designed for community pharmacies. You may decide, however, that it is appropriate to administer it in other types of pharmacies, such as pharmacies in an integrated health care system or a hospital, or pharmacies that supply dispensed prescriptions only to hospices or nursing homes.

We recommend administering the survey in pharmacies with at least five staff members (unless the data will be used in combination with other pharmacy stores). Staff in smaller pharmacies may not feel that their answers are anonymous and may not be willing to complete the survey or answer honestly. In small pharmacies, you can use the survey as a tool to initiate staff discussion about patient safety issues. 

We also recommend that there be at least five respondents in a pharmacy for a survey feedback report to be provided, to protect respondent anonymity. Small pharmacies that are part of a larger chain could have their data aggregated with other stores for feedback purposes.

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Identification of Survey Participants

General criteria. 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 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.

Types of staff. Include staff working daytime, evening, and nighttime shifts in the pharmacy area. This group may include pharmacy clerks and cashiers, pharmacy technicians and aides, pharmacy student interns/externs, and pharmacists (pharmacy managers, pharmacists in charge, staff pharmacists, and pharmacy residents).

You should also include the following types of staff if they meet the general criteria above—that is, they interact with other pharmacy staff working in the dispensing area of your pharmacy and do so often enough to be able to report on the topics assessed in the survey:

  • Pharmacy delivery staff.
  • Pharmacist and technician floaters.
  • Part-time pharmacy staff.
  • Store general manager.
  • New employees.

Overall, when considering who should complete the survey, ask yourself:

  • Does this person know about day-to-day activities in the dispensing area?
  • Does this person interact regularly with staff working in the dispensing area?

Staff or managers working at more than one pharmacy site. Pharmacy chains or systems may have some staff or managers who work at more than one site. In such cases, distribute the survey to them at the site where they spend most of their time and instruct them to answer about that pharmacy only. If they spend an equal amount of time at multiple pharmacies, choose one pharmacy site at which they will receive the survey and instruct them to answer the survey only for that pharmacy.

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Patient Safety Culture Composites

The 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 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.

Table 1. Patient Safety Culture Composites and Definitions
Patient Safety Culture Composite Definition: The extent to which…
Communication About Mistakes Staff discuss mistakes that happen and talk about ways to prevent mistakes
Communication About Prescriptions Across Shifts Information about prescriptions is communicated well across shifts and there are clear expectations and procedures for doing so
Communication Openness Staff freely speak up about patient safety concerns and feel comfortable asking questions; staff suggestions are valued
Organizational Learning—Continuous Improvement The pharmacy tries to figure out what problems in the work process lead to mistakes and makes changes to keep mistakes from happening again
Overall Perceptions of Patient Safety There is a strong focus and emphasis on patient safety and the pharmacy is good at preventing mistakes
Patient Counseling Patients are encouraged to talk to the pharmacist; pharmacists spend enough time talking to patients and tell them important information about new prescriptions
Physical Space and Environment The pharmacy is well organized and free of clutter; the pharmacy layout supports good workflow
Response to Mistakes The pharmacy examines why mistakes happen, helps staff learn from mistakes, and treats staff fairly when they make mistakes
Staff Training and Skills Staff get the training they need, new staff receive orientation, and staff have the skills they need to do their jobs well
Staffing, Work Pressure, and Pace There are enough staff to handle the workload, staff do not feel rushed, staff can take breaks, and work can be completed accurately despite distractions
Teamwork Staff treat each other with respect, work together as an effective team, and understand their roles and responsibilities

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Modifications to the Survey

The survey was developed to be general enough for use in most pharmacies. But your pharmacy's management may want to ask additional questions about patient and medication safety and quality assurance. We recommend making changes to the survey only when absolutely necessary, because any changes may affect the reliability and validity of the survey and make comparisons with other pharmacies difficult.

Adding items.If your pharmacy adds items to the survey, add these items toward the end of the survey (just before the Background Questions section). 

Removing items. Although the survey takes about 10 to 15 minutes to complete, you may want to administer a shorter survey with fewer items. If so, review the list of survey composites and items, identify specific composites your pharmacy does not want to assess, and delete all items in those composites. This way, your pharmacy's results on the remaining patient safety culture composites can still be compared with results from other pharmacies using the survey. We do not recommend selectively removing items across composites.

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Content of This Survey User's Guide

The survey, this user's guide, and other toolkit materials are available on the AHRQ Web site (http://www.ahrq.gov/professionals/quality-patient-safety/surveys/pharmacy/). These materials are designed to provide pharmacies with the basic knowledge and tools needed to conduct a patient safety culture assessment, along with ideas for using the data. This guide provides a general overview of the issues and major decisions involved in conducting a survey and reporting the results.

Part One of the user's guide includes the following chapters:

  • Chapter 2—Getting Started: Provides information on project planning, data collection methods, survey identifiers, vendors, project timelines, project teams, and pharmacy points of contact.
  • Chapter 3—Using Paper Surveys: Addresses how paper surveys will be distributed and returned, techniques for publicizing and promoting the survey, recommended data collection steps, and survey materials.
  • Chapter 4—Using Web-Only and Mixed-Mode Surveys: Covers techniques for publicizing and promoting a Web survey, data collection steps for Web-only surveys and for mixed-mode surveys, Web survey communications, and guidelines for Web survey design and pretesting.
  • Chapter 5—Analyzing Data and Producing Reports: Discusses the steps needed to prepare the data file, reviews analysis issues, and provides suggestions for producing feedback reports.

Part Two of the guide includes the pharmacy survey and a list of the survey items organized by the patient safety culture dimensions they are intended to measure. The appendix includes three sample data collection protocols for pharmacies to use during survey administration: one for paper-only survey administration, one for Web only, and one for mixed mode.

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Current as of March 2013
Internet Citation: Chapter 1. Introduction: Pharmacy Survey User's Guide. March 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/pharmacy/toolkit/pharmsopsuserguide1.html