238 Background: Safety reporting is imperative because it provides an opportunity to identify and address preventable errors to enhance patient safety. Pharmacists at the Massachusetts General Hospital cancer center have historically submitted the highest number of safety reports compared to clinicians/nursing. This past year, however, there was a decline in the number of reports submitted. Because pharmacists are in a key position to monitor patient safety, this study was conducted to characterize safety reports submitted by pharmacists and describe subsequent action plans. Additionally, pharmacists’ attitudes towards safety reporting were assessed and obstacles identified. Methods: A retrospective analysis of medication safety reports submitted by outpatient staff over the past 4 years was conducted. Data were obtained from institutional safety reporting system. Pharmacy procedures and education materials were compared against safety reports. Pharmacists’ attitudes were assessed using online survey adapted from the AHRQ. Results: Pharmacists consistently submitted more safety reports compared to other disciplines. However, safety reporting declined from a mean of 61 reports annually to 40 in 2013. The majority of reported events involved prescribing errors, followed by orders submitted to pharmacy without meeting treatment criteria. Actions plans included: protocol checklists, staff education and updating order sets. The majority of pharmacists surveyed agreed/strongly agreed that the practice is actively doing things to improve patient safety and mistakes have led to positive changes. When an event is reported, almost 50% of pharmacists indicated infusion unit staff perceive the person is being written up, not the problem. Common barriers to reporting were time constraints, nurses taking reports personally and not knowing which events warrant reporting. Conclusions: Pharmacists at our institution play an integral role in safety reporting which is essential to provide quality patient care and enhance patient safety. Obstacles identified in this study may have contributed to the recent decline in reporting. Opportunities exist to reinforce non-punitive nature of safety reporting.
Chemotherapy Errors: A Call for a Standardized Approach to Measurement and Reporting