Form #3 Form #3 Draft Pharmacy Background Questionnaire

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

Attachment E

Draft Pharmacy Background Characteristics

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 Laura [email protected].

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

(Last): __________________________________________________________

Primary National Pharmacy Identifier (NPI): _____________________________

Job Title: ________________________________________________________

Name of Pharmacy: _______________________________________________

Pharmacy Mailing Address: (Street): ______________________________________

(City) (State) (Zip code)

POC Phone: Fax: Email:­­­­­­­­­­­­­­­­­­­_________________

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

 a. Independently owned pharmacy (1 to 4 pharmacies only)  GO TO Question 4.

 b. Chain pharmacy

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

 a. Traditional chain drugstore (e.g., Walgreens, CVS)

 b. Supermarket pharmacy

 c. Mass merchant pharmacy (e.g., Target, Costco, Meijer, Wal-Mart)

 d. Other (Please specify): ______________________________________________

3. How many stores/sites does this chain include?

 a. 4 to 9

 b.10 to 49

 c. 50 to 99

 d. 100 to 499

 e. 500 or more

 f. Don’t know

Public reporting burden for this collection of information is estimated to average 10 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.

4. 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. 12,001 or more per week

5. 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

6. 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

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

 a. Yes

 b. No

8. Does this pharmacy use a central fill for dispensing any prescriptions?

 a. Yes

 b. No

9. Do the pharmacists working in this pharmacy belong to a union?

 a. Yes

 b. No

10. Do the technicians working in this pharmacy belong to a union?

 a. Yes

 b. No

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

	Yes, we currently use this tool ▼	No, but we plan to use this tool within the next 6 months ▼	No, and we do not plan to use this tool within the next 6 months ▼
a) Scanner to import paper prescriptions into a pharmacy computer?	1	2	3
b) Electronic prescriptions?	1	2	3
c) Barcode verification of medications during filling?	1	2	3
d) Barcode verification of medications during final check?	1	2	3
e) Picture of drug on computer to compare with vial contents?	1	2	3
f) Image of original prescription on computer display during final check?	1	2	3
g) Picture of drug with imprint code on the prescription label or patient information?	1	2	3
h) Computer alerts for drug-drug interactions?	1	2	3
i) Robotic dispensing system?	1	2	3
j) Automated pill-counting device (nonrobotic)? (Please describe): ____________________________________________________	1	2	3
k) Automated system (fax machines, voice mail, touch tone telephone prompts, or email) for patients to request prescription refills?	1	2	3
l) Other automated tools? (Please describe): ____________________________ ____________________________ _____________________________	1	2	3

12. Does this pharmacy currently provide the following clinical services:

	Yes ▼	No, but we plan to provide this in the next 6 months ▼	No, and we do not plan to provide this in the next 6 months ▼
Vaccinations?	1	2	3
Medication therapy review to identify and resolve medication-related problems?	1	2	3
Consultation services for complex medical conditions?	1	2	3
Screening and wellness services (e.g., asthma, diabetes, heart disease, smoking cessation, weight loss)?	1	2	3
Coaching and support for disease management (e.g., diabetes, asthma, COPD, heart failure, Parkinson’s disease)?	1	2	3
Anticoagulation management (e.g., in- pharmacy finger sticks and INR testing, patient education, dose adjustments)?	1	2	3
Other clinical services (Please specify): ______________________ _____________________________ _____________________________	1	2	3

13. Does this pharmacy compound any drug products on site?

 a. Yes, a little

 b. Yes, a lot, including complex compounding

 c. No

13. Does this pharmacy currently have a formal system for reporting errors to the pharmacy owner or designated corporate entity?

• a. Yes

• b. No

• c. Don’t know

13. 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. Other? (Please specify): _____________________ _________________________________________	1	2	3

Draft Background Characteristics Form, February 8, 2011 – Developed by Westat – Do Not Circulate