Patient Safety and the Role of a Specialty Pharmacist in a Health System

March 4, 2021
Kami Nolan, PharmD, CSP and Jill Paslier, PharmD, CSP

Due to the high-touch, high-risk nature of specialty medications, specialty pharmacies must incorporate robust programs to ensure proper medication usage and minimize the potential for error or adverse events.

The specialty pharmacist has a unique role in medication safety. Not only are they responsible for ensuring safe, effective, appropriate use of specialty medications—and ensuring that the patient is educated on their therapy and can be adherent—but they also play a strong role in promoting a positive safety culture within their pharmacy setting.

Due to the high-touch, high-risk nature of specialty medications, specialty pharmacies must incorporate robust programs to ensure proper medication usage and minimize the potential for error or adverse events. Engaging specialty pharmacy staff members in the importance of patient safety and creating a just culture can have a strong influence on patient safety and the reduction of errors.

Culture determines the extent to which the pharmacy team will communicate safety concerns, strive to learn and modify behavior based on lessons learned, and show a personal responsibility toward patient safety.

Health care is inherently complex and risky. As we know, to err is human, and we all make mistakes. This is why it is so important to promote a positive safety culture and proactively find ways to implement strategies to improve the systems where we work.

In a pharmacy with a just culture, there is open and honest reporting of medication safety concerns as a way to promote learning and preventing future errors and patient harm. Just culture changes the focus from errors and outcomes to system design and management of staff behavioral choices: human error, at-risk-behavior, and reckless behavior.

In 2012, the Agency for Healthcare Research and Quality (AHRQ) conducted the Hospital Survey on Patient Safety Culture. The survey was created for providers and staff to assess patient safety culture in their hospitals by asking questions about the organizational culture’s support for patient safety.

The survey looks at staff perceptions and concerns in regard to patient safety problems and error reporting. More than half of respondents revealed that mistakes are held against them and the person is written up instead of the problem being addressed.

In specialty pharmacy, there are many processes and procedures in place to prevent or catch mistakes. These are reviewed continuously in order to ensure quality programs are in place. Differentiating between human-error, at-risk-behavior, and reckless behavior is important because errors are often a result of system issues, rather than employee issues.

By incorporating pharmacy staff (pharmacists and technicians) into the quality improvement process and error-reporting process, one can engage with all team members and also show that collectively we can find solutions to a potentially bigger issue with the process already in place. In turn, employees can feel involved with decisions and more comfortable with identifying and reporting errors. AHRQ has a complimentary Patient Safety Culture survey available for community and specialty pharmacies to use as a tool to measure and respond to their organization’s safety culture.

Error reporting is essential to a healthy safety culture. Error reporting can help health care providers learn about potential risks, actual errors, causes of errors, and ways to prevent errors and patient harm. Some people hesitate to report errors because it is extra work, and/or they may be worried about getting themselves or others in trouble.

Pharmacy leaders and those responsible for collecting and reviewing error reports can do these things to positively impact the reporting culture:

  • Earn the trust of reporters and ensure that those who are involved in and report errors are not punished.
  • Keep the identity of the reporter and those involved in the error confidential to prevent embarrassment.
  • Consider the format and length of the report, making sure it is clear and easy for the reporters. If the reporting form is too long, people will not want to take the time to complete it.
  • Along with health system leadership, acknowledge and reward those who submit error reports as they are playing a positive role in patient safety.
  • Provide rapid, useful, and understandable feedback to staff so they are informed about how their reports are being used to improve system processes.
  • Mentor staff about the error-reporting process to reinforce that error reporting is important in maintaining patient safety.


Specialty pharmacy staff can report errors through their health system event reporting program. According to the AHRQ Hospital Survey on Patient Safety Culture, only 65% of respondents indicated that they were informed about errors in their unit.

Health system specialty pharmacies are in a unique position in that they are aligned with multiple pharmacy departments throughout an organization. Specialty pharmacy staff can share “good catches” when an error is found prior to reaching a patient. These good catches can be shared across pharmacy departments within organizations in order to increase awareness and to recognize those promoting medication safety.

Specialty pharmacies can also report errors externally to take part in shared learning. ISMP hosts a public practitioner-based medication error reporting portal. When you report errors through this portal, many are investigated by ISMP medication safety experts with the prospect of sharing lessons learned.

ISMP publishes de-identified examples of error reports received in their Community/Ambulatory Care ISMP Medication Safety Alert! Newsletter, which includes recommendations for other pharmacies to prevent these types of error or harm within their own practice setting. Pharmacy staff can learn about risks in other community pharmacy settings by reviewing this newsletter or ISMP Medication Safety Alert! Action Agendas- Ambulatory Care, which is a simplified version of the issues and actions recommended in the newsletter.

Proactively reviewing published safety literature in the pharmacy can help promote a positive safety culture and allow the team to identify opportunities to prevent errors and patient harm. The Excelera Network, a nationwide network of health system specialty pharmacies, provides a great example of shared learning opportunities between health system specialty pharmacies through a medication safety user group that meets quarterly.

Specialty pharmacists can positively influence medication safety culture within their pharmacy by promoting just culture, encouraging staff reporting of errors (inside and outside of the organization), and taking part in patient safety culture surveys. A positive patient safety culture engages all staff in the quality improvement and error-reporting process, empowering staff to find solutions to process issues as a means to prevent errors, in an effort to minimize patient harm.

CHI Health is a member of the Excelera Network.

About the Authors
Kami Nolan, PharmD, CSP, Pharmacy Manager, CHI Health Specialty Pharmacy
Jill Paslier, PharmD, CSP, International Safe Medication Management Fellow, ISMP

References

  1. Ahrq.gov. 2018. SOPS Surveys. [online] Available at: [Accessed 24 February 2021].
  2. ISMP. A lot happens when you report a hazard or error to ISMP- there’s no “black hole” here! Community/Ambulatory Care ISMP Medication Safety Alert! 2020; 19(9):1-4.
  3. ISMP 2012. Just Culture and Its Critical Link to Patient Safety (Part I). [online] Available at: [Accessed 24 February 2021].
  4. ISMP. 2012. Just Culture and Its Critical Link to Patient Safety (Part II). [online] Available at: [Accessed 24 February 2021].
  5. ISMP. Pump up the volume- Tips for increasing error reporting. Community/Ambulatory Care ISMP Medication Safety Alert! 2006; 5(10):1-3.
  6. ISMP. The differences between human error, at-risk behavior, and reckless behavior are keys to a Just Culture. Community/Ambulatory Care ISMP Medication Safety Alert! 2020; 19(10):1-6.
  7. Judy, S., 2020. Just Culture. [Presentation]
  8. Philip G. Boysen, I., 2013. Just Culture: A Foundation for Balanced Accountability and Patient Safety. [online] PubMed Central (PMC). Available at: [Accessed 23 February 2021].
  9. Psnet.ahrq.gov. 2019. The Pharmacist's Role in Medication Safety. [online] Available at: [Accessed 23 February 2021].