Form 2 Pharmacy Background Characteristics Form

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

ATTACHMENT B

Pharmacy Background Characteristics Form

To Be Completed by Pharmacy Point-of-Contact for Each Pharmacy Administering the Pharmacy Survey on Patient Safety

Instructions: Please provide the following information, which will be used to analyze data collected with the Pharmacy Survey on Patient Safety. If you need assistance in answering any of the questions, please email DatabasesOnSafetyCulture@westat.com.

Name of Pharmacy Point-of-Contact (POC):

(First Name)

(Last Name) _____________________________________________________

Job Title: ________________________________________________________

Name of Pharmacy: _______________________________________________

Store Number: ____________________________________________________

Pharmacy Address: (Street) _________________________________________

(City) (State) (Zip code)

POC Phone: Fax: Email:_­­­­­­­­­­­­­­­_________________

1. Please check the type of store that best describes this pharmacy (Mark ONE only).

a. Independent pharmacy

b. Supermarket pharmacy

c. Mass merchant pharmacy / discount retailer pharmacy

d. Chain drugstore (local, regional, national)

e. Integrated health system pharmacy

f. Other (Please specify): ______________________________________________

2. Number of locations/stores affiliated with this pharmacy:

Include this pharmacy when counting.

a. 1 store (This pharmacy is the only location).

b. 2 to 3

c. 4 to 9

d. 10 to 99

e. 100 or more locations/stores

f. Don’t know

Public reporting burden for this collection of information is estimated to average 5 minutes per response, the estimated time required to complete the survey. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.

3. What is the average number of prescriptions dispensed PER WEEK in this pharmacy?

a. 700 or fewer per week

b. 701 to 1,500 per week

c. 1,501 to 3,000 per week

d. 3,001 to 6,000 per week

e. 6,001 to 12,000 per week

f. More than 12,000 per week

4. On average, how many hours PER WEEKDAY (Monday–Friday) is this pharmacy open?

a. 8 or fewer hours per weekday

b. 9 to 12 hours per weekday

c. 13 to 15 hours per weekday

d. 16 to 23 hours per weekday

e. 24 hours per weekday

5. How many days a week is this pharmacy open?

a. 5 or fewer days a week

b. 6 days a week

c. 7 days a week

6. Does this pharmacy currently have a drive-through window?

a. Yes

b. No

7. Does this pharmacy use a central fill (i.e., an offsite facility) for dispensing any prescriptions?

a. Yes

b. No

8. What are the number of employees by staff type?

Staff Type	Number
Pharmacists
Pharmacy Technicians
Pharmacy clerk or pharmacy cashier
Pharmacy student intern/extern
Other

9. Does this pharmacy currently use the following automated (electronic) technologies:

	Yes, we currently use this tool ▼	No, we do not currently use this tool ▼
a) Scanner to import paper prescriptions into a pharmacy computer?	1	2
b) Barcode verification of medications?	1	2
c) Robotic filling system?	1	2
d) Automated pill-counting device (nonrobotic)? (Please describe):	1	2
e) Picture of drug on computer to compare with prescription?	1	2
f) Image of original prescription on computer display during final check?	1	2
g) Automation at pickup to prevent wrong patient error (e.g., cash register programmed to ask for and enter date of birth through scanning or manual input prior to dispensing)?	1	2
h) Other automated tools? (Please describe):	1	2

9. Does this pharmacy currently provide the following clinical/medication therapy
management services:

	Yes ▼	No ▼
Medication therapy management to identify and resolve medication-related problems?	1	2
Screening and wellness services (e.g., asthma, diabetes, heart disease, smoking cessation, weight loss)?	1	2
Coaching and support for disease management (e.g., diabetes, asthma, COPD, heart failure, Parkinson’s disease)?	1	2
Other clinical services (Please specify):	1	2

10. Does this pharmacy compound any medications on site?

a. Yes

b. No ► GO TO Question 12

10. What type of compounding does this pharmacy do: simple, complex, or both?

a. Simple only

b. Complex only

c. Both simple and complex

10. Does this pharmacy currently report any errors to external reporting programs, such

as the following:

	Yes ▼	No ▼	Don’t Know ▼
a) The Institute for Safe Medication Practices (ISMP) Medication Errors Reporting Program (MERP)?	1	2	3
b) MedWatch – The FDA Safety Information and Adverse Event Reporting System?	1	2	3
c) Federally certified Patient Safety Organization (PSO) other than ISMP?	1	2	3
d) Private company providing error monitoring services to pharmacies?	1	2	3
e) Other? (Please specify):	1	2	3

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