Home Support ISMP Newsletters Webinars Report Errors Educational Store Consulting FAQ Tools About Us Contact Us
ISMP Facebook

Community Pharmacy Medication Safety TOOLS AND RESOURCES

The Institute for Safe Medication Practices (ISMP) frequently receives inquiries regarding what components comprise a medication safety program for community pharmacy practice. Listed below are several tools, as well as suggestions on how to use them, to help in this endeavor. Practice settings which can benefit from these tools include: home care infusion organizations, mail order pharmacies, community pharmacies, and other ambulatory or outpatient settings.


High-Alert Medications Consumer Leaflets

Between 2008 and 2012, the Institute for Safe Medication Practices (ISMP) was awarded a grant from the Agency for Healthcare Research and Quality to conduct a study in community pharmacies regarding the impact of counseling consumers who pick up prescriptions for certain high-alert medications. The medications involved in this study include:

  • Warfarin
  • Enoxaparin
  • Fentanyl patches
  • Methotrexate (oral)
  • Hydrocodone with acetaminophen
  • Oxycodone with acetaminophen
  • Insulin analogs (lispro, aspart, glargine, glulisine, detemir)
Assessing Barcode Verification System Readiness in Community Pharmacies

Assessing Barcode Verification System Readiness in Community Pharmacies is a free tool to help community pharmacies prepare for future implementation of a barcode product verification system. The tool helps pharmacy leaders and staff evaluate their current workflow, standard operating procedures, and technology to identify what needs to be accomplished before implementing a barcode product verification system. The assessment process makes the adoption of this technology less stressful and more efficient because pharmacy staff are better prepared to adapt to any necessary changes that have been foreseen by using the tool.

The actual assessment items are divided into two parts—one group of assessment items for pharmacy leaders/owners, and another group of assessment items for pharmacy staff. Background information on barcode technology and Appendices on Elements to Consider During Vendor Selection and Direct Costs Associated with Barcode Verification Systems are also provided.

This assessment tool was developed by the Institute for Safe Medication Practices and funded by the Agency for Healthcare Research and Quality


Root Cause Analysis (RCA) Workbook for Community/Ambulatory Pharmacy

The Root Cause Analysis (RCA) Workbook for Community/Ambulatory Pharmacy is designed to assist community pharmacy personnel in completing RCA for a sentinel event that may have occurred in their pharmacy.  RCA for sentinel events is required in the Center for Pharmacy Practice Accreditation’s (CPPA) standards developed by the National Association of Boards of Pharmacy (NABP), American Pharmacists Association (APhA) and American Health System Pharmacy Association (ASHP) as well as by several boards of pharmacy.

This RCA workbook is suitable for use in community pharmacy, mail order pharmacy or other ambulatory pharmacy practice settings that need to investigate a sentinel event. For more information and to access the workbook, go here,

Root Cause Analysis Workbook for Community/Ambulatory Pharmacy© is a copyrighted workbook of the Institute for Safe Medication Practices (ISMP). ISMP does not endorse any software or training for the Root Cause Analysis Workbook for Community/Ambulatory Pharmacy© process that is not directly provided by ISMP.

This workbook or parts of it may be printed for individual use or distributed for training purposes within your organization.
No one may alter the content in any way, or use the workbook in any commercial context, without written permission from the Institute for Safe Medication Practices.


Improving Medication Safety in Community Pharmacy: Assessing Risk and Opportunities for Change

Improving Medication Safety in Community Pharmacy: Assessing Risk and Opportunities for Change is designed to help community pharmacy personnel identify potential medication safety risks and prevent error. Pharmacists and other pharmacy personnel can use the materials and tools in this manual to pinpoint specific system weakness in the medication-use processes and to provide a starting point for successful organizational improvements. After utilizing this manual, community pharmacy personnel will be able to: 1) initiate a risk assessment process to identify system-based medication safety improvements in the community pharmacy setting, 2) use ISMP’s Key Elements of the Medication Use System™ to help identify and prevent risk in daily practice, 3) examine flow diagrams or flow charts of the medication process to identify variability in current medication-use processes, 4) select effective error reduction strategies that can prevent patient harm, 5) apply knowledge of ISMP’s Key Elements to identify breakdowns in the system that have contributed to the error, and 6) utilize the Assess-ERR™ for a medication error or near miss that has occurred in your practice.

For more information and to access the manual, go here.


ISMP Medication Safety Self Assessment® for Community/Ambulatory Pharmacy

The ISMP Medication Safety Self Assessment® for Community/Ambulatory Pharmacy is designed to heighten awareness of distinctive characteristics of safe pharmacy systems. This comprehensive tool also will help you assess the safety of medication practices in your pharmacy and identify opportunities for improvement.

The self-assessment characteristics in the tool are based upon ISMP’s expertise in analyzing medication errors reported to the ISMP National Medication Errors Reporting Program, evidence-based research on the most effective error-reduction strategies, professional practice standards, and system improvements that have been recommended during our on-site consultations with pharmacies.

The self assessment is divided into ten key elements that most significantly influence safe medication use. Each element is defined by one or more core characteristics of a safe pharmacy system that further define a safe medication use system. Each core characteristic contains individual self-assessment items to help you evaluate your success with achieving each core characteristic.

A team of staff (including owners/managers, staff pharmacists, pharmacy technicians, and pharmacy students) should be established at each pharmacy site to collaboratively assess safety practices using the assessment. A consensus on the responses should then be gathered and opportunities for improvement should be discussed. A plan with goals including system changes with resources needed should be developed and implemented to achieve short and long term improvements in medication safety. The self assessment should be used as an ongoing safety project in your medication safety program.

For more information and to download or print a free copy of the self assessment, go here.

ISMP Medication Safety Alert!® Community/Ambulatory Care Edition

This innovative newsletter—sent monthly by e-mail—brings you vital and potentially life-saving information about medication-related errors, adverse drug reactions, as well as recommendations that will help you reduce the risk of medication errors and other adverse drug events in your community practice site. The ISMP Medication Safety Alert!® Community/Ambulatory Care Edition is targeted toward pharmacists, pharmacy technicians, nurses, physicians, and other community health professionals. In addition to the newsletter, ISMP sends urgent advisories about serious errors or information that requires immediate attention to its subscribers.

Information found in the ISMP Medication Safety Alert!® Community/Ambulatory Care Edition stems from error reports submitted voluntarily by practitioners and consumers to the ISMP Medication Errors Reporting Program and the FDA MedWatch program. ISMP independently reviews and analyzes all reports, performs additional investigation when required on a confidential basis, seeks outside expert review, and informs industry and regulatory authorities as necessary, before preparing material for publication and dissemination.

The newsletter should be distributed to and discussed with all staff in order to evaluate if the errors occurring elsewhere can occur in your organization. This is a proactive learning tool that should be incorporated into your medication safety program.

Individual subscription rates to the ISMP Medication Safety Alert!® Community/Ambulatory Care Edition are $60 per year for 12 monthly issues. Discounts are available for organizations with multiple sites or multiple users. For more information or to subscribe, go here or contact ISMP at 215-947-7797.


ISMP Ambulatory Care Action Agenda

Another way to utilize the ISMP Medication Safety Alert!® Community/Ambulatory Care Edition is by using the Action Agenda. Three times a year, selected items are prepared for you and your staff to stimulate discussion and collaborative action to reduce the risk of medication errors. The agenda topics appeared in the ISMP Medication Safety Alert!® Community/Ambulatory Care Edition during the preceding 4 months. Each item includes a brief description of the medication safety problem, recommendations to reduce the risk of errors, and the newsletter issue number to locate additional information as desired. The action agenda is presented in a format that allows community practice sites to document their medication safety activities, which is important for internal quality improvement efforts but also may be important for any external accrediting or regulatory organizations. To view the ISMP Ambulatory Care Action Agenda, go here to learn more about how to use ISMP Ambulatory Care Action Agenda click here.


Principles of Designing a Medication Label for Community and Mail Order Pharmacy Prescription Packages

Standardized and well thought drug labeling practices need to be a part of an overall strategy to improve medication adherence and reduce inadvertent medication errors in community pharmacy. To review ISMP'S recommendations for the prevention of errors related to label misinterpretation, go here.

Assess-ERR™ Community Pharmacy Version

The ISMP Assess-ERR™ is a simple three step medication system worksheet designed to assist pharmacists and pharmacy operators with error report investigations. Use the Assess-ERR™ tool to record errors, near-errors, and/or hazardous conditions. Examples of errors to address with the Assess-ERR™ tool include dispensing the wrong drug, strength, or dose; look-alike/sound-alike errors; calculation or preparation errors; misuse of devices; and errors in prescribing, transcribing, dispensing, and/or monitoring of medications.

Using the Assess-ERR™ helps a pharmacy convert a negative error experience into a positive learning experience that enhances the overall future safety of that pharmacy’s practice. The tool aids in developing a standardized approach to documenting error incidents and helps to reveal the underlying system deficiencies that may have caused or contributed to the error. Additionally, the tool can help raise awareness of issues that have become so familiar to pharmacists in a particular practice setting that the issues are no longer even recognized as risks.

To download the Assess-ERR ™ Community Pharmacy Version electronically fillable and/or a printer-friendly version, go here.
America's Medicine Cabinet "Use Medicines Safely" Campaign

Three tools listed below will assist community pharmacists in education the public about safe medication use. These tools were made possible through a grant from the Community Pharmacy Foundation and involving collaboration between the Institute for Safe Medications Practices (ISMP) and the American Pharmacists Association (APhA).  Components of the campaign include:

(1) Presentation to Consumers:  a PowerPoint presentation with speaker’s notes for delivery by pharmacists to consumer audiences on the safe use of medicines, including reading medication labels and following medication instructions, health literacy, medication disposal and utilizing the services provided by pharmacists. To see the presentation and speaker notes, go here.

(2) Patient Education Brochure: a patient education brochure on the safe use of medicines developed by ISMP. To view and download the brochure, go here.

(3) Call to Action: a Call to Action White Paper issued by ISMP on medication safety in the United States and the role of the pharmacist. To view or download the white paper, go here.

For more on this campaign go to


Medication Error Reporting

The ISMP Medication Errors Reporting Program (MERP), operated by ISMP, is a confidential national voluntary reporting program that provides expert analysis of the system causes of medication errors and disseminates recommendations for prevention. Without reporting, such events may go unrecognized and thus important preventive and epidemiological information would be unavailable. Regulatory agencies and manufacturers are notified when changes are needed in products.

Reporting errors to external reporting programs is an important element of a complete medication safety program and demonstrates your practice’s commitment to sharing information on medication errors so that others may learn. To report errors, near-errors, or hazardous conditions, please go here.


Eliminating the Use of Error-Prone Abbreviations

Some abbreviations, symbols and dose designations are frequently misinterpreted and lead to mistakes that result in patient harm. They should NEVER be used when communicating medical information. This includes telephone/verbal prescriptions, labels for drug storage bins, computer-generated labels, medication administration records, as well as pharmacy and prescriber computer order entry screens. To help practitioners identify those abbreviations that have been associated with medications errors reported to the ISMP Medication Errors Reporting Program, ISMP has created a list of error-prone abbreviations which can be found here. The FDA has joined with ISMP to launch a national campaign to help eliminate the use of ambiguous medical abbreviations. Information regarding the campaign, as well as an abbreviations toolkit, can be found here.

Posted on November 13, 2007. Updated January 11, 2010


Home | Contact UsEmployment  | Legal Notices | Privacy Policy | Help Support ISMP
Med-ERRS Med-ERRS | MSOMedication Safety Officers Society | Consumer Medication SafetyFor consumers
 ISMP Canada ISMP Canada | ISMP Spain ISMP Spain | ISMP Brasil ISMP Brasil | International Group | Pennsylvania Patient Safety Authority

200 Lakeside Drive, Suite 200, Horsham, PA 19044, Phone: (215) 947-7797,  Fax: (215) 914-1492
© 2017 Institute for Safe Medication Practices. All rights reserved