Measuring Use of the Joint Patient Safety Reporting System for Patient Safety at the VA: Perspectives from the Field

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) and the VA National Center for Patient Safety (NCPS), we are interested in understanding how pharmacists use JPSR in the Pharmacy Service at their sites to monitor, track and report medication error related adverse events as well as 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 was to understand how VA sites are currently using JPSR to report medication error related adverse events and/or close calls. Survey response rate was 67.1% (N=98).

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 respondents (98.0%) reported that in general, their site uses JPSR to report medication adverse events and/or close calls. Findings showed that JPSR reports are reviewed most often by Patient Safety Managers/Officers (18.4%), Pharmacy Managers (13.8%), Pharmacy and Therapeutics Committees (12.5%), Chiefs of Pharmacy (11.5%), Patient Safety Committees (10.6%), Medication Safety Pharmacists/Officers (9.8%) and the Medication Safety Committees (9.3%). Proportion of pharmacists that indicated having criteria or specific definition guiding the reporting of either medication adverse events and/or close calls are as follow: 45.9% both; 36.8% neither;1.0% medication adverse events only; 2.0% close calls only; and 14.3% didn’t know.

VA sites rely heavily on the use of the JPSR system to report medication error related adverse events and/or close calls to manage medication safety for Veterans.