Pharmacists for Patient Safety Network
- Need: Pharmacists in rural Nebraska are often isolated and find it difficult to communicate with others about safety concerns.
- Intervention: The Pharmacists for Patient Safety Network was a communication network in which pharmacists identified safety concerns and shared solutions.
- Results: After one year of implementation, 30 of the 38 participating pharmacies reported that the network encouraged new safety practices and reinforced existing safety strategies.
Rural pharmacists often work alone and have few
colleagues close by to discuss safety concerns. A high
demand for services and a small workforce of pharmacists
can lead to prescription errors, as mistakes may slip by
a pharmacist working to fill prescriptions for an entire
town or county.
The Pharmacists for Patient Safety Network began in 2011
so that Nebraska pharmacists could report errors and
share solutions with other pharmacists. In the past,
researchers collected data on errors and safety concerns
reported across the country, but they could not provide
timely feedback to help pharmacists correct these issues.
The Pharmacists for Patient Safety Network provided
participating pharmacists with suggestions for solving
their safety concerns.
The Pharmacists for Patient Safety Network collaborated
- Nebraska Department of Health and Human Services
- Nebraska Pharmacists Association
- Nebraska Board of Pharmacy
- Nebraska Office of Rural Health
The network was funded by:
- Agency for Healthcare Research and Quality (AHRQ)
- Nebraska Office of Rural Health
- Community Pharmacy Foundation
While the program is no longer ongoing, program
researchers hope that findings from the development,
implementation, and one-year assessment of the program
and its effectiveness can be a foundation for development
of future similar efforts.
Pharmacists in Nebraska volunteered to participate in the
Pharmacists for Patient Safety Network. Participants used
the online system to report:
- Errors (preventable events that may lead to
inappropriate use or harm)
- Near misses (events that could have caused harm but
- Safety concerns (risk-generating
processes that can lessen the quality of patient care)
In the reporting system, participants described what
happened, how it was discovered, how/whether a patient
was affected, and what steps the pharmacy was taking to
prevent similar issues in the future.
The program offered solutions and suggestions in the form
of educational leaflets via email. For example, if a
physician prescribed a pediatric oral suspension
(children's medication in liquid form) and the dosage
amount was misinterpreted by the pharmacist, leaflets
suggested that physicians list a child's weight on the
prescription and that pharmacists double-check
calculations and ask for clarification on any
prescriptions that seem incorrect.
After one year of implementation, 9 patient safety event
reports were submitted. Of the 38 participating
pharmacies, 30 had completed interviews with researchers,
discussing the effectiveness of the network and possible
ways to improve it. Participants reported that the
- Improved awareness of safety concerns
- Led to implementation of proactive safety practices
- Promoted discussion of safety practices
- Was effective overall in
improving safety practices in rural pharmacies
For more detailed program results:
Galt, K.A., Fuji, K.T., & Faber, J. (2013). Patient
Safety Problem Identification and Solution Sharing among
Rural Community Pharmacists. Journal of the American
Pharmacists Association, 53(6), 584-594.
There was low participation in the first year of the
program, especially in reporting errors and near misses.
Researchers began to make follow-up phone calls every 1
to 2 months to encourage pharmacists to use the reporting
system. In addition, researchers made site visits,
encouraging pharmacists to join the network and educating
them about the importance of error reporting.
The primary barrier is time. Some participating
pharmacists reported that they did not have enough time
to use the reporting system, much less read the leaflets.
Pharmacists recognize that patient safety is important,
but their workload often inhibits basic patient safety
Use multiple communication routes, such as email and fax,
and tailor communication routes to match pharmacists'
preferences. Early on in the program, six pharmacists
reported that their email systems sent the leaflets to
their spam folders.
Understand that a large quantity of reports is not
necessary to enhance patient safety practices. If an
error has occurred once, it can occur again in the
- Ground the program's underlying framework in patient
- Make regular contact with participants, through phone
calls and site visits
- Involve pharmacists in generating strategies to
facilitate error reporting
- Be persistent. Culture change takes time
Kevin T. Fuji, PharmD, MA, Associate Professor of Pharmacy Practice
Creighton University School of Pharmacy and Health Professions
Networking and collaboration
Pharmacy and prescription drugs
Technology for health and human services
August 12, 2016
Date updated or reviewed
September 28, 2022
Suggested citation: Rural Health Information Hub,
Pharmacists for Patient Safety Network [online]. Rural Health Information Hub. Available at:
[Accessed 5 February 2023]
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about this program. Summaries of models and innovations are provided by RHIhub for your convenience. The
programs described are not endorsed by RHIhub or by the Federal Office of Rural Health Policy. Each rural
community should consider whether a particular project or approach is a good match for their community’s
needs and capacity. While it is sometimes possible to adapt program components to match your resources, keep
in mind that changes to the program design may impact results.