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Pharmacists for Patient Safety The State of
Patient Safety in Nebraska Pharmacy Kevin T Fuji,
PharmD Kimberly A. Galt, PharmD, PhD(c) Roger
Kaczmarek Alexandra B Serocca, BS Ashley D
Pham, PharmD Charles C Barr, PharmD Mark V
Siracuse, PharmD, PhD James D Bramble, PhD
Bartholomew Clark, PhD Chris J Bradberry, PharmD
Background
Results
Analysis
Results

• Error Reporting and Practice Improvement System
• 42 indicated a willingness to share safety
  experiences and suggestions for improving
  practice through a common database

• Descriptive and relational statistics were
  performed on the quantitative
• data.
• Thematic analysis of open ended text responses
  were performed.
• Comparison of the quantitative findings were
  made to the qualitative
• findings to further explain the meaning of the
  quantitative findings and
• interpret the importance.

• Pharmacists Stories about Safety Issues in
  Practice
• Pharmacists also shared 649 stories about a wide
  range of safety issues of importance to their
  practice.
• Representative pharmacist story
• A prescription was written for fluoxetine. The
  pharmacy technician had the fluoxetine stock
  bottle and trazodone stock bottle on the counter.
  The technician scanned the fluoxetine bottle, was
  interrupted, and then counted and dispensed
  trazodone. The pharmacist did not catch this
  error. The patient took trazodone in the morning
  and nearly fell asleep at work. The pharmacy
  lost the patients trust, disciplined the staff,
  and realized they were overworked and
  understaffed. This, along with the
  implementation of a new computer system likely
  led to the error.

• Pharmacists play a central role in patient
  safety, as health professionals who have arguably
  the most interaction and easiest access to
  patients in most care and community settings.1
• There is a need to determine the prevalent
  patient safety issues that have a timely concern
  to pharmacists and their patients to help
  pharmacists develop approaches to minimize risk
  and harm.
• The increasing complexity of pharmacists
  practice (medication therapy management services
  (MTMS)use of health information technology as
  examples) will continue to be challenged to
  identify safety problems and produce solutions.

• Pharmacists Safety Improvement and Error
  Experiences with Health Information Technology
• We asked pharmacists to identify the specific
  kinds of errors that they experienced as a result
  of using specific technologies and the specific
  kinds of improvements, or error reductions, for
  these same technologies. Pharmacists shared 540
  stories, about one half of these being stories
  about errors they believe increased as a result
  of the technology and about one half about errors
  they believed decreased, or improvements that
  resulted from these technologies.
• E-prescribing is used as an example
• Representative error reduced as a result of the
  technology
• Enhanced legibility has led to a reduction in
  errors.
• Representative error observed as a result of
  this technology
• The wrong drug is selected from the menu (i.e.,
  oral, dissolvable tablet). The days supply may
  not match the days supply calculated by the sig.
  
• The health information technologies pharmacists
  were asked about are listed below.

Results

• Patients Safety Concerns Told to Their
  Pharmacists
• Pharmacists provided 250 stories that patients
  shared with them about safety concerns
• Patients told their stories about receiving wrong
  medications, doses, and duplications of therapy
  with some experiencing negative outcomes
  patients described confusion and mistrust of
  their pharmacist due to generic medications whose
  names and appearance differ from the brand
  medication when dispensed errors related to
  their childrens medications medication recalls
  medication interactions and problems with mail
  order pharmacies.
• Representative patient story
• Patient felt that we didnt provide adequate
  instructions on a prescription for prednisone. We
  could not fit all instructions on the bottle, so
  we abbreviated the instructions. The patient
  couldnt understand the instructions. Patient
  ended up taking the prescription wrong.
• Pharmacists Experiences with Errors and Near
  Misses
• 362 (68) pharmacists reported being involved in
  or observing errors or near misses in the six
  months prior to the study. The distribution of
  errors and near misses reported is shown below.

Objectives
Conclusions

• To describe the patient safety issues pharmacists
  and their patients face across the spectrum of
  practice and geographic settings in Nebraska
• To disseminate these findings to pharmacists and
  key stakeholders for use in policy formation and
  practice improvement.

• Pharmacists experience many errors and near
  misses in practice.
• Pharmacists want to engage in communication
  about safety concerns and
• participate in an information sharing and
  learning network to improve patient
• safety in their practices.
• The need to learn continuously from each other
  in the pharmacists
• professional community about important safety
  issues and to develop a rapid
• dissemination system to communicate potential
  solutions back for
• pharmacists to incorporate into local practice
  is evident.

Demographics
Implications for Policy and Practice

• 535 pharmacists in practice responded,
  representing 24 of pharmacists in Nebraska in
  all health care delivery settings. Pharmacists
  have been in practice for an average of 21 years,
  with the distribution of respondents 56 female
  and 95 White.

This joint effort with the Nebraska State Board
of Pharmacy produced the first comprehensive
State of Patient Safety in Nebraska Pharmacy
report. The findings are being used to inform
pharmacists, patients, health professionals,
policy makers, scientists, and other stakeholders
the compelling case for establishing and on-going
learning community with a rapid educational
feedback system to improve patient safety through
a network of communication across the state.
Health Information Technology
References

• Institute of Medicine. To Err is Human Building
  a Safer Health System. Washington, DC National
  Academy Press, 1999. Available at
  http//www.nap.edu. Accessed September 2007.

Methods and Design
Funding Sources

• Nebraska Department of Health and Human Services
  State Board of Pharmacy
• Dyke Anderson Patient Safety Grant

• A cross-sectional mixed methods study using a
  written survey, Pharmacists for Patient Safety,
  was distributed to all pharmacists licensed in
  the state of Nebraska (n2,195).
• Quantitative and qualitative responses to survey
  items were solicited.

For More Information
CHRP website http//chrp.creighton.edu CHRP
e-mail chrpinfo_at_creighton.edu