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 is a communication network in which pharmacists can identify safety concerns and share 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.
Evidence-levelEffective (About evidence-level criteria)
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 with:
- Nebraska Department of Health and Human Services
- Nebraska Pharmacists Association
- Nebraska Board of Pharmacy
The network was funded by:
- Agency for Healthcare Research and Quality (AHRQ)
- Nebraska Office of Rural Health
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 did not)
In this 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 network:
- Improved awareness of safety concerns
- Led to implementation of proactive safety practices
- Promoted discussion of safety practices
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. Article Abstract
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 practices.
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 future.
- Ground the program's underlying framework in patient safety science
- 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
Contact InformationKevin T. Fuji, Director
Center for Health Services Research and Patient Safety
Networking and collaboration
Pharmacy and prescription drugs
Technology for health and human services
August 12, 2016
Date updated or reviewed
August 7, 2019
Please contact the models and innovations contact directly for the most complete and current information 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.