1. Can a Culture of Safety be Enhanced in a
Department of Pharmacy?
Heather Kertland, Clarence Chant, Salma Satchu, Jill Garland, Elaine Tom
Department of Pharmacy, St Michael’s Hospital, Toronto, ON

2. Culture of Safety in Pharmacy Department
Context:
 To determine if we could positively influence the overall safety culture within a
Department of Pharmacy in a tertiary/quaternary teaching institution
Problem:
 Rapid and substantial changes within our medication system and pharmacists
workflow revealed new potential for medication errors as well as increasing
reports of errors
Intervention:
 Education – two lectures on science and safety and safety culture
 Baseline assessment of safety culture using the Hospital Survey on Patient
Safety Culture
 Implemented a 4 month pilot of bi-weekly Safety Rounds, an open
communication forum for discussion of medication errors by pharmacists that
was lead by the Professional Practice Leader
 Re-measured safety culture one month after pilot
 Pharmacists’ satisfaction and feedback gathered at end of each rounds

3. Culture of Safety in Pharmacy Department
Results of the Hospital Survey of the Patient Safety Culture
Pharmacists’ satisfaction and feedback
100%
strongly agree
50% agree
neutral
0% disagree
Worth my Enhanced Felt Will make
time awareness comfortable changes strongly disagree

4. Culture of Safety in Pharmacy Department
Contribution to Patient Safety and Quality Improvement
 While overall safety culture did not improve, there were important increases in
positive responses in certain domains, and most importantly, increased
recognition of high potential for errors associated with changes with our
medication system
 Decreases in positive response in domains such as hospital management
support for patient safety may reflect challenges with implementing
recommended system-wide changes for errors discussed at rounds within a
short timeframe
Lessons Learned
 Further interventions are required given the multiple domains comprising
safety culture
 Identified the need to create work group to follow-up on recommendations
brought forward during rounds
 Identified need for continuation of Safety Rounds as evidenced by high
attendance and active participation