Evaluation of the Joint Patient Safety Reporting System for Patient Safety: Pharmacists’ Perspectives

ANJU SAHAY, PhD
Dept. of Veterans Affairs

The focus of the Department of Veteran Affairs’ (VA) Center for Inpatient Medication Safety (CIMS) is to reduce medication errors for hospitalized Veterans. For the VA and the Defense Health Agency, the Joint Patient Safety Reporting (JPSR) system standardizes event capture and data management of medical errors and near misses. In collaboration with the VA Office of Pharmacy Benefits Management Services (PBM), we are interested in understanding how VA pharmacists use JPSR at their sites to monitor, track and report medication error related adverse events and/or close calls.

Pharmacists at all the VA sites.

In November 2021, jointly CIMS and PBM conducted a web-based survey. VISN (Regional) Pharmacy Executives at 18 VISNs were emailed a survey weblink to forward to the Chiefs of Pharmacy at all the sites within their own VISN who, in turn, identified a pharmacist with knowledge of the JPSR system at their site to complete the survey. The goal of the survey was to understand how pharmacists perceived the use of JPSR to report medication adverse events and/or close calls. Survey response rate was 67.12% (N=98).

A majority of the respondents (pharmacists) self-reported their primary role as Pharmacy Manager (49.5%), Patient/Medication Safety Pharmacist (21.6%), Clinical Pharmacy Specialist (8.2%), Chief of Pharmacy (6.2%), Quality Management Pharmacist (3.1%), Staff Pharmacist (2.1%), and Pharmacoeconomist (2.1%). Remaining pharmacists (7.2%) identified themselves singularly (1.0%) in each of the remaining 7 primary roles. Almost all the pharmacists (96.0%) reported that they and/or other pharmacist(s) use JPSR to report medication adverse events and/or close calls. The remaining pharmacists did not use (2.0%) and did not know (2.0%) about the use of JPSR. Regarding how often JPSR medication adverse event reports and/or close calls were reviewed by the Pharmacy Service at their site, respondents stated that these reports are reviewed: daily (34.9%), weekly (28.9%), bi-weekly (1.2%), monthly (32.6%), quarterly (1.2%) and never (1.2%). In general, to understand medication adverse events and/or close calls these pharmacists considered the JPSR reports as useful with responses ranging from quite useful (61.3%), somewhat useful (34.4%) to not useful (4.3%). Focusing on those pharmacists (96.0%) who responded that they and/or other pharmacists use JPSR to report medication adverse events and/or close calls, we found that reporting of medication error related adverse events occurred often (67.8%), sometimes (25.6%), and rarely (6.7%). Similarly, reporting of close calls in JPSR occurred often (53.9%), sometimes (34.9%) and rarely (11.2%).

Pharmacists perceive the JPSR system as valuable and useful to report medication error related adverse events and/or close calls to manage medication safety for Veterans.