ISMP tool helps community pharmacies put patient safety first

Self-assessment tool targets safety in workflow, immunizations, labeling, and storage

How can pharmacists be sure they’re doing everything possible to keep their patients safe? With pharmacy practice growing increasingly complex, it can be tricky for already-busy practices to keep track of all the variables that can influence medication safety. A revised self-assessment tool from the Institute for Safe Medication Practices (ISMP), the 2017 ISMP Medication Safety Self-Assessment for Community/Ambulatory Pharmacy, aims to help community and ambulatory pharmacy teams develop an accurate picture of where they are hitting or missing safety targets in areas like workflow, immunizations, labeling, and storage—and to continuously strive for more.

The self-assessment tool is divided into 10 elements that influence safe medication use, each defined by one or more core characteristic of a safe pharmacy system. Each core characteristic contains a series of individual self-assessment questions—216 in all.

“When a medication error occurs it is at least in part a systems failure,” said Michael T. Rupp, PhD, professor of pharmacy at Midwestern University College of Pharmacy—Glendale, a member of the advisory panel that helped ISMP create the tool. “We have a tendency to slip into shortcuts that maybe initially we recognized weren't perfectly consistent with our policies and procedures, but we got away with it and we kept doing it. We need to be reminded once in a while of what best practices are and why.”

Completing the self-assessment tool is a team effort. “One of the self-assessment items asks if patient allergies is a required field,” said Donna Horn, RPh, DPh, ISMP director, patient safety-community pharmacy. “And the pharmacist could say, ‘Yes, we always get patients’ allergies,’ but the technician might say, ‘Well, we get them for most people, but not everybody.’ Depending on who’s working at that station, they would be able to answer that question more thoroughly.”

Jaime Montuoro, PharmD, director of the residency program at Smith’s Food and Drug Centers in Salt Lake City, said her residents began using the ISMP tool this year as part of their required quality improvement projects. But just taking the assessment can benefit safety. “A resident suggested sharing the results in team meetings, listing the things that we need to have our eye on,” she said. “People will start looking at how they can modify what they’re doing even outside the formal quality improvement project.”

Patient safety issues attracted attention as a result of a December 2016 Chicago Tribune story on how often pharmacies identified and warned patients about potentially dangerous drug combinations. Pharmacy advocates have criticized it, but Rupp said the article “could actually do us a service because it reinforces the value of implementing things like ISMP’s medication safety self-assessment. I think it reflects how important it is that a pharmacy, a manager, a pharmacy organization, and even pharmacist practitioners understand safety.”

“At the end of the day, patient safety is our number one job. No matter what else we do, if we can’t ensure safety in the use of medications, then everything else is moot,” Rupp added.

Visit to access the self-assessment and associated resources.

For the full article, please visit for the June 2017 issue of Pharmacy Today.