Developing a medication-safety self-assessment tool for rural primary care units - A case from Finnish Lapland

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With a specific, proactive, medication-safety self-assessment tool designed for rural primary care units, healthcare professionals could identify development needs in their medication processes. Methods The Delphi consensus method with two Delphi rounds was used to create a medication-safety self-assessment tool for rural primary care units in Finnish Lapland. A preliminary tool was designed based on three national and international risk management tools. Statements of the preliminary tool were evaluated with a two-round Delphi panel by 12 experts in primary care and patient safety. Evaluated aspects were suitability for primary care settings, patient safety relevance, and necessity of the statements to be included in the developed rural, primary care, medication-safety self-assessment tool. Results In the first Delphi round, a consensus was reached on 39% of the statements (n = 118/304), of which 86% (n = 101/118) were included, and 14% (n = 17/118) were excluded from the final primary care medication- safety self-assessment tool. In the second round, 84% of the statements (n = 141/167) reached a consensus, of which 70% (n = 98/141) were excluded and 30% (n = 43/141) included in the final tool. The included 144 statements were divided into 12 thematic sub-groups: 1. Patient information, 2. Drug information, 3. Communication of drug orders and other drug information; 4. Drug labeling, packaging and nomenclature; 5. Drug storage and distribution, 6. Medication device acquisition and use, 7. Environmental factors, workflow and staffing patterns; 8. Staff competency and education, 9. Patient education, 10. Preventive risk management, 11. Learning from medication safety incidents, and 12. Electronic health record. Conclusions The developed medication-safety self-assessment tool is targeted for proactive medication risk management in rural primary care settings. While experts reached a consensus for the PMSSA tool contents, adoption of the tool to suit the rural primary care environments in different countries should be further investigated. medication safety medication process risk management primary care risk assessment rural self-assessment Figures Figure 1 Figure 2 Figure 3 1. Background Medication errors, described as any preventable event that may cause or lead to inappropriate medication use or patient harm [ 1 , 2 ], are among the most commonly reported adverse incidents in European healthcare [ 2 – 4 ]. While several studies have aimed to promote systems-based medication safety in hospitals, less emphasis has been placed on proactive medication risk management in primary care settings, especially in rural area hospitals [ 5 ]. In rural areas, the population is often older and tends to suffer more from chronic diseases than do residents of non-urban regions [ 6 – 10 ]. Consequently, rural primary care has unique challenges, often involving complex medical cases and limited resources [ 6 , 11 – 17 ]. To tackle these problems, previous studies have suggested various approaches, such as strengthening multi-professional collaboration [ 18 – 23 ], establishing remote pharmacy services [ 18 , 19 ], and developing public health programs aiming at medication process evaluation and enhanced safety of care providers [ 24 , 25 ]. To systematically control the risks associated with the medication process, rural primary care units could benefit from introducing proactive approaches, such as medication safety self-assessment (MSSA), to uncover the central risk points of care [ 16 ]. MSSA tools have been adopted for medication risk management in healthcare systems of different countries [ 26 – 29 ]. They use a systematic, collaborative process to evaluate the unit's medication safety guidelines and practices under investigation. However, current MSSA tools focus mainly on the issues of large hospitals and complex tertiary care [ 6 , 26 , 30 – 32 ], while MSSA tools with targeted primary care criteria have not yet been developed. Due to varying risk profiles in different care environments [ 4 ], current MSSA tools may not provide an optimal risk assessment strategy for small rural hospitals with limited resources. In rural areas, such as Finnish Lapland, a key deficiency is often the experienced lack of pharmacy professionals in local primary care settings. Therefore, identifying medication safety risks may need to rely more on the contribution of other available local healthcare professionals, with remote pharmacy services being supportive. An MSSA tool targeted for medication risk management of rural primary care units would need to encompass the before-mentioned special features of the respective environment. However, to our knowledge, no such adopted MSSA tools currently exist. Using Finnish Lapland as a case example, this study aimed to develop a comprehensive yet practical MSSA tool for rural primary care settings (PMSSA) with limited resources to ensure safe local medication processes. 2. Methods Study context In 2023, Finland established a nationwide public healthcare reform [ 33 , 34 ], creating 21 wellbeing services counties as service organizers and providers. A central goal of the reform was to ensure equal services and to reduce regional health and well-being inequalities among Finnish citizens. By law, the well-being service counties are responsible for self-monitoring produced services. Therefore, the counties must prepare an electronic self-monitoring plan concerning quality control, risk management, and patient safety[ 35 ]. The present study was conducted in the rural Lapland area of Finland. The Lapland Wellbeing Services County is responsible for offering health and social services to its inhabitants. Lapland is Finland’s largest and northernmost area (Fig. 1 ). The area of the Lapland region is 100,367 km 2 with a population density of 1.9 people/km 2 , and 25% of the population is over 65 years old and has a high rate of chronic diseases [ 36 , 37 ]. There are two special care hospitals in Lapland Wellbeing Services County, whereas primary care services are produced in 21 units within the area, with 630 inpatient beds [ 38 ]. Altogether, six hospital pharmacies support the healthcare units (Fig. 1 ), but most primary care units in Lapland lack comprehensive hospital pharmacy services due to long distances. Consequently, pharmacy services provided for the primary care units are mainly remote services far from the primary care unit (Fig. 1 ). Typical remote services include overnight delivery of medicines and clinical pharmacy services offered by phone, such as information on intravenous medication administration incompatibles and instructions for using new medicines. Pharmacy services related to long-term medication risk management, medicine handling, and appropriateness of medication-related facilities are inadequate. Improving medication safety through self-monitoring in rural Lapland would require new techniques, such as PMSSA, independent of local hospital pharmacy services. Delphi consensus method This study used the Delphi method to develop a PMSSA tool for rural Lapland. The Delphi technique is a multistage process for deriving consensus among separate experts [ 39 – 42 ], and it has been previously used in developing MSSA tools for various healthcare settings [ 26 , 43 , 44 ]. The method effectively allows a group of individuals to deal with complex problems based on principles of anonymity, iteration, and feedback [ 42 , 45 ]. The anonymity of the answers will enable individuals to freely express their thoughts and ideas without fearing judgment. The present study used the eDelphi software, allowing the researchers to observe whether the individual panelists had entered the questionnaire platform. This enabled the monitoring of participation activity and kept all panelists involved until the end of the study. The present study comprised three phases, including two Delphi rounds with six questionnaires (Q1-6). The Delphi questionnaires with instructions were emailed to the panelists between December 2021 and April 2022. After two weeks, the link for each questionnaire was resent, and panelists who had not yet answered were personally reminded. Each questionnaire was kept open until all panelists delivered their responses, and the following questionnaire was released. A descriptive quantitative analysis with numbers and percentages was conducted using MS Excel by the main researcher (PS). Delphi panelists A convenience sample of individuals (n = 12) identified as primary care and patient safety experts in the Lapland area were contacted by phone and asked to participate in the study in November 2021. After the contacts, the study's introductory written material was emailed to the experts to confirm their participation. In total, 10 panelists agreed to participate. The group was further strengthened with two additional experts from the Finnish Center for Client and Patient Safety to provide a national perspective for developing a specific region-based risk management tool. The final Delphi panel (n = 12 experts) consisted of four nurses, five pharmacists, and three physicians. Phase I: Developing the Delphi instrument Three existing proactive risk management tools were identified to develop the Delphi instrument (Fig. 2 ). The first tool was a recently updated MSSA tool targeted at Finnish hospitals [ 43 ]. The tool originates from the Institute for Safe Medication Practices (ISMP) MSSA tool[ 27 ], which was adapted to the Finnish healthcare environment in 2016 [ 26 , 43 ]. The second source was the National Guideline for Safe Medication Management and Use in Finland [ 46 ]. The guideline recommends that Finnish care units (e.g., hospital wards and nursing homes) develop internal protocols for safe medication practices. The third tool was the Hospital Survey on Patient Safety Culture by the Agency for Healthcare Research and Quality [ 47 ]; patient safety culture assessment tools are recommended to be used as part of the regular safety assessment in hospitals [ 48 ]. To develop the Delphi instrument, the contents of the three selected risk management tools were combined to form statements. The statements (n = 436) were further formatted by the study group members (PS, EC, SS, A-RH), who had clinical and academic expertise in proactive medication risk management. As a part of the process, the statements were formatted into the same configuration, favoring a positive approach, e.g., the statement: “In this unit, there is a lack of support for staff involved in patient safety errors” was formatted to “There is enough support for staff involved in patient safety errors”. Additionally, statements concerning specialized health care were irrelevant to rural primary care in Lapland and removed (e.g., central anaesthesia). Statements from different sources with similar meanings were integrated to form one statement. E.g., the following individual statements were integrated into one statement: “ An employee’s competence in pharmacotherapy is verified in the manner defined in the unit’s safe medication management and use protocol before the employee can start implementing pharmacotherapy independently for the patients” and “ All new employees and substitutes involved in the medication process are assessed for competency before they begin independent work. The authorization to work independently is given in writing. It is part of the orientation documentation of the employee ”. The new single statement was: “ The qualifications of all new employees and substitutes (including doctors and nurses) participating in pharmacotherapy are assessed in the manner defined in the unit-based safe medication management and use protocol before they start working independently. The authorization to work independently is given in writing and is part of the orientation documentation”. After formatting, the study group identified the following main themes among the statements: 1. Leadership, 2. Personnel and actions in hazard incidents, 3. Environment, equipment and software, and 4. Medication process (Fig. 2 ). A separate questionnaire was formed for each theme, and four patient safety and primary care experts were invited to validate the questionnaires as pre-Delphi. Based on the pre-Delphi, one statement was clarified, and a six-step evaluation scale of the statements was altered into a four-step scale (Fig. 2 ). Delphi round 1 In the first Delphi round, four questionnaires (Q1-4), each representing one of the four themes, were administered to the panelists (Appendix 1). The panelists evaluated each statement based on its importance to medication safety and the primary care environment by using a four-step scale (- / + / ++ / +++), in which “-“ represented “not important at all” and “+++” represented “highly important”. The practicality of the PMSSA tool to be developed was emphasized to the panelists, meaning the tool should be comprehensive but concise enough to be used in small primary care units. The final tool should also exclude self-evident or otherwise unnecessary statements inappropriate to primary care settings. Consequently, the panelists were asked to be critical in their evaluation of the statements. The panelists were also invited to suggest alterations or new statements and provide relevant comments. All comments by the panelists were anonymous but visible, and the panelists could comment on each other’s notions during the Delphi round. During the analysis, answers - and + were combined into one category of “not sufficiently important or essential” to achieve a concise PMSSA tool concentrating on the most pertinent prioritized statements. Correspondingly, answers + + and +++ were categorized as “sufficiently important and essential”. On the first Delphi round, if ≥ 50% of the panelists had indicated an individual statement as “not sufficiently important or essential”, the statement was excluded from the PMSSA tool. The statements with a consensus of ≥ 85% on being “sufficiently important and essential” were included directly in the PMSSA tool. The representative consensus limits were chosen to identify the most critical issues to be evaluated in the PMSSA tool without becoming too broad for practice. Statements which did not reach consensus during the first Delphi round were re-evaluated in the second Delphi round. Delphi round 2 Before administering the second Delphi, the statements were altered based on panelists’ comments from the first Delphi round. To facilitate ease of answering, four themes were combined into the following two questionnaires: Leadership, personnel and actions in hazard incidents (Q5), and Environment, equipment, software and medication process (Q6). The panelists were also provided access to statements already included in the PMSSA tool, comments made in the first round, and the original statement if the statement was re-formatted. In the second round, the panelists were asked to evaluate the necessity of the statement to be included in the PMSSA tool on a scale of yes/no. Similarly, as in the first round, the Delphi panel could suggest alterations or new statements or provide other comments; all comments were anonymous but visible to all panelists during the questionnaire. The statements with a consensus of > 50% were included or excluded from the PMSSA tool. The study group evaluated statements with a precisely 50% level of agreement to decide whether to include or exclude them; the decision was based on the panelists’ comments, previously included statements, and study group evaluation. Phase III: Developing the PMSSA tool The study group developed the final PMSSA tool based on the statements included in the Delphi process (Fig. 3). The PMSSA tool was developed by re-grouping the included statements into smaller sub-groups based on the previously developed Finnish MSSA tool for secondary care settings [ 43 ] and adding a scale of evaluation for each statement. Also, user instructions were provided in the final tool. 3. Results All agreed panelists (100%, n = 12) participated in all Delphi questionnaires (Q1-6) during the two Delphi rounds. The average response rate to the statements (n = 471) of the questionnaires was 93%. The lowest response rate to single statements was 75%, concerning nine out of 471 statements. The results of the present study comprise the consensus reached in the two Delphi rounds, the description of the panelists’ comments during the rounds, and the final PMSSA tool developed based on the included statements. The reached consensus, and the panelists’ comments In the first Delphi round (Q1-4), a consensus was reached on 118 out of 304 statements (39%), of which 86% were included, and 14% were excluded from the final PMSSA tool. During the first Delphi round, the panelists (n = 12) provided 198 comments to the statements (n = 304) of the administered questionnaires (Q1-4) (Table 1 ). Based on the comments, 25 statements were altered, one statement was added, and 20 were combined with another statement due to similarities. In the second round (Q5-6), 141 out of 167 statements (84%) reached a consensus, of which 70% were excluded and 30% included in the final PMSSA tool. The consensus percentages varied between 32%-46% for the first round of Delphi questionnaires (Q1-4), while consensus percentages of 77% and 90% were achieved for the questionnaires (Q5-6) in the second round (Table 2 ). Table 1 The number and types of comments provided for each questionnaire (Q1-6) by the panelists (n = 12) during the Delphi rounds. Suggestions for new statements (n = 1) Suggestions for content alterations (n = 31) Supporting opinions for inclusion (n = 34) Supporting opinions for exclusion (n = 65) Other comments (n = 82)* In total (n = 213) Round 1 Q1 : Leadership 0 8 8 31 22 69 Q2 : Personnel and action in hazard incidents 0 9 12 5 32 58 Q3 : Environment, Equipment and Software 0 4 6 3 9 22 Q4 : Medication process 1 8 7 17 16 49 Total/round 1 1 29 33 56 79 198 Round 2 Q5 : Leadership, personnel and action in hazard incidents 0 1 1 5 1 8 Q6 : Environment, Equipment, Software and Medication process 0 1 0 4 2 7 Total/round 2 0 2 1 9 3 15 *Non-relevant content for formatting, adding, including or excluding the statements. During the second Delphi round, the panelists provided 15 comments to the statements (n = 167) in both administered questionnaires (Q5-6) (Table 1 ), with the majority (n = 9) concerning supporting opinions for the exclusion of statements. There were no suggestions for new statements. Consequently, the statements for which the consensus was reached (Figs. 3 and Table 2 ) were included or excluded from the final PMSSA tool without any changes. Table 2 The number of included and excluded statements, the level of the achieved consensus for each Delphi questionnaire (Q1-6), and the results of study group evaluation between the Delphi rounds. Q1: Leadership (n = 71) Q2: Personnel and action in hazard incidents (n = 58) Q3: Environment, equipment, and software (n = 60) Q4: Medication process (n = 115) Delphi round I* Included 26 21 12 42 Excluded 7 2 7 1 Level of achieved consensus 26% 40% 32% 37% Formatting, adding, and combining statements by the study group Formatted 6 8 4 7 Added 1 0 0 0 Combined 3 9 4 4 Q5: Leadership, personnel, and action in hazard incidents (n = 75) Q6: Environment, equipment, software, and Medication process (n = 92) Delphi round II** Included 18 25 Excluded 40 58 Level of achieved consensus 77% 90% *The required consensus rate was ≥ 50% for excluding and ≥ 85% for including a statement on the first Delphi round; **the required consensus rate was > 50% for including and excluding a statement on the second Delphi round. The final PMSSA tool In total, 148 statements were included after Delphi rounds. However, when forming the final PMSSA tool (Appendix 2), the study group combined four statements which were considered similar. The included statements were further classified based on the ISMP MSSA tool for hospitals [ 27 ] with some alterations. “Quality, processes and risk management” was divided into two sections: “Proactive risk management” and “Learning from medication safety incidents” to increase practicality. In addition, a section for “Risk management supporting features of electronic medication record software” was added. Thus, in the final PMMS tool (Appendix 2), the approved statements (n = 144, Fig. 3) were divided into the following twelve thematic sub-groups (n of statements per sub-group provided in brackets): 1. Patient information (n = 9), 2. Drug information (n = 10), 3. Communication (n = 19), 4. Drug labeling, packaging and nomenclature (n = 6), 5. Drug storage and distribution (n = 11), 6. Medication device acquisition and use (n = 7), 7. Environmental factors, workflow and staffing patterns (n = 13), 8. Staff competency and education (n = 15), 9. Patient education (n = 10), 10. Quality control and risk management (n = 18), 11. Learning from medication safety incidents (n = 18), and 12. Risk management supporting features of electronic medication record software (n = 8). An evaluation scale was adopted for the PMSSA tool from the Medication Safety Self-Assessment Tool for Hospitals in Finland [ 43 ]. In the final PMSSA tool, each statement is evaluated on a four-level scale for the existing part of the instructions and the level of implementation (Table 3 ). Table 3 The measuring scales of the statements (i.e., procedures to enhance medication safety) in the final PMSSA tool (Appendix 2).* Scale for availability of instructions on procedures Scale for implementation of procedures Scale Description Scale Description Comprehensively instructed. The procedure described in the statement has been fully guided, and all the staff have become familiar with the instructions and internalized their content. Orientation is documented for the whole staff (e.g., with reading receipts). Used comprehensively The procedure described in the statement is followed in every situation in the unit, and the entire staff follows it. Partially instructed. The procedure described in the statement is outlined in the unit. However, the instructions are insufficient to allow staff to follow the procedure described. The entire staff is not familiar with the instructions. The orientation documentation has been partially completed. Partially used The procedure described in the statement is followed occasionally in certain situations, and/or some of the staff follow the procedure. Not instructed. The procedure described in the statement has not been instructed at all in the unit, although it should be. Not in use The procedure described in the statement is not in use at all in the unit, although it should be. N/A The procedure described in the statement does not apply to the unit’s operation. N/A The procedure described in the statement does not apply to the unit’s operation. * Adopted from the Medication Safety Self-Assessment Tool for Hospitals in Finland [ 43 ] and modified by the study group. 4. Discussion A committed inter-professional panel of medication and patient safety experts contributed to this Delphi study, enabling the development of a self-assessment tool for evaluating medication safety in rural primary care settings in Lapland. To our knowledge, this is the first study to introduce a medication risk management tool focusing on the specific needs of a particular setting of a demographically demanding area. Several other MSSA tools concerning medication safety in different environments have been developed internationally and in Finland over the past years [ 26 – 28 , 32 , 43 , 44 ]. The present tool represents a continuation of the previous MSSA tools for hospitals [ 26 , 43 ], which have been well received and adopted as a part of national medication safety guidelines in Finland [ 46 ]. In this PMSSA tool, similar thematic sub-groups were formed as in the previous Finnish MSSA tool for hospitals, but in the new primary care-focused tool, the priorities and contents differed from the previous secondary care-focused tools. The final PMSSA tool consists of 144 statements, less than in many other national and international MSSA tools [ 27 , 43 , 49 ]. Compared to the previous secondary care-focused Finnish MSSA tool [ 43 ], the number of statements remained almost the same in the ‘Patient Information and Communication’ sub-groups. This indicates that establishing procedures for safe handling of patient information and effective means of communication are equally important in both secondary and primary care. The number of statements in sub-groups “The medication device acquisition and use” and “Drug storage and distribution” was significantly less than in the previous Finnish MSSA tool. This may result from having fewer medication treatment-related devices, complex medication treatments, or high-risk administration routes in primary care, reducing their potential for confusion. No sub-group of PMSSA tool received more statements than the previous MSSA tool. Based on the expert evaluation during the first Delphi round of the study, the highest degree of consensus was reached on the leadership-related statements. Indeed, leadership is one of the most critical factors affecting organizations’ ability to adopt medication safety practices across types of healthcare organizations [ 50 , 51 ]. In contrast, the smallest consensus during the first Delpihi round was reached on the theme of “Environment, equipment, and software”. This could reflect that the health units' seek independence in choosing their working tools and software, potentially representing a reason why the experts' assessments of their importance to patient safety varied. While there are indications that the quality of healthcare in rural areas of Finland may lag behind the development of the rest of the country [ 7 ], understanding patient safety concepts and building a patient safety culture in rural Lapland remains a central target for public health development, to which the present tool aims to contribute. Similarly to in other rural areas, the healthcare system in Lapland uses many remote connections, which should be considered when developing functioning procedures for medication safety [ 6 , 23 , 52 ]. The present PMSSA tool can be used to provide the primary care units with the possibility to independently identify their most critical areas for improvement without the demand for a direct onsite contribution from pharmacy professionals. However, in the case of Lapland, we recommend that the pharmacies still coordinate the self-assessment in healthcare units, which could be completed by the units at least before their annual remote audition. Consequently, pharmacy professionals can focus on supporting the units in managing the most critical and complex medication safety risks during the audits. Limitations and recommendations Delphi is a subjective evaluation method; its reliability is affected by the choice of experts, i.e., the number and quality of panelists [ 39 , 40 , 42 ]. While panels of 10–23 experts are generally considered sufficient [ 42 ], it was considered essential to keep all the panelists (n = 12) involved in all questionnaires (Q = 1–6). To ensure the participation of all panelists, statements with consensus on the first Delphi round did not go through the second round iteration. Therefore, to control the bias, the first-round consensus rate was set high. Additionally, the researcher’s influence was minimized by setting the consensus limit of the second round so that only statements with which exactly half of the panelists disagreed remained for the researchers to evaluate [ 39 , 45 ]. The PMSSA is recommended to be adopted as a part of regular organization-level self-monitoring of care quality and a means for information-based management of health services. In the future, the PMSSA tool should be evaluated as to whether it is compact but comprehensive enough to fulfil its purpose. Also, the PMSSA tool has a potential to be transferable to sparsely populated, technically developed regions of primary care services in other countries. However, the tool should be validated to suit the local regulations, policies, and cultural dimensions that affect risk management practices [ 53 ]. 5. Conclusions The present study introduces a PMSSA tool developed for rural primary care units to support their proactive medication risk management. A consensus of a committed expert group was achieved on the contents of the PMSSA tool. While remote pharmacy services, distinct to rural areas, emphasizes the importance of self-assessment by units, pharmacy support is still recommended to manage the assessment and related risk management development activities of the units. In the future, the adoption of the tool should be validated to suit risk management practices in different rural primary care environments in different countries. Abbreviations PMSSA Primary Care Medication Safety Self-Assessment MSSA Medication Safety Self-Assessment ISMP Institute for Safe Medication Practices Declarations Ethics approval and consent to participate Not applicable. A study approval was obtained from the Lapland Central Hospital. A separate ethics committee approval was not sought as the study contained no patients or patient information. The study was carried out in accordance with the National Research Ethics Guidelines and Regulations (Finnish Advisory Board on Research Integrity. Responsible conduct in research and procedures for handling allegations of misconduct in Finland [54]. A written consent was obtained from all participants. Consent for publication Not applicable. Availability of data and materials Materials described in the manuscript, including all relevant raw data, are available from the corresponding author PS to any scientist wishing to use them for non-commercial purposes. Competing interests The authors declare no conflict of interest. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Authors’ contributions Each manuscript author (PS, EC, SS and AH),has contributed to the study’s planning, conducting and reporting. Acknowledgements The authors thank the Delphi panelists for their valuable contributions to this study, pre-Delphi participants, and Professor Marja Airaksinen for participating in the commencement of the study. Supplementary information Appendix 1. Questionnaires Q1-Q4 Appendix 2. PMSSA-tool. References Weingart SN, Wilson RM, Gibberd RW, Harrison B. Epidemiology of medical error. Br Med J. 2000;320(3):774–7. 10.1136/ewjm.172.6.390 . WHO. Patient safety - Data and statistics. 2021. https://www.euro.who.int/en/health-topics/Health-systems/patient-safety/data-and-statistics . Council of Europe. Creation of a better medication safety culture in Europe: Building up safe medication practices. Council of Europe. 2007. http://optimiz-sih-circ-med.fr/Documents/Council_of_Europe_Medication_Safety_Report_19-03-2007.pdf . Accessed on 14 Feb 2021. WHO. Medication Without Harm - Global Patient Safety Challenge on Medication Safety. Geneva: WHO. 2017 p. 16. https://iris.who.int/bitstream/handle/10665/255263/WHO-HIS-SDS-2017.6-eng.pdf?sequence=1 . Accessed on 7 Mar 2021. Grativol MS, Mendes Junior WV. Patient safety in primary health care: a systematic review. Cad Saúde Publica. 2014;30(9):1815–35. 10.1590/0102-311X00114113 . American Hospital Association, American Society of Health-System Pharmacists, Hospitals & Health Networks. Medication Safety Issue Brief. Small and rural hospitals–unique challenges, unique solutions. Hosp Health Netw. 2005;79(11):45–6. https://pubmed.ncbi.nlm.nih.gov/16396133/ . Accessed on 24 Aug 2022. Satokangas M. Geographic equity in primary health care performance in Finland: from individual socioeconomic position into the blind spot of the service system. Helsinki: University of Helsinki, Faculty of Medicine; 2021 p. 1–84. http://hdl.handle.net/10138/334486 . Accessed on: 1 Jun 2022. Borda-Olivas A, Fernández-Navarro P, Otero-García L, Sanz-Barbero B. Rurality and avoidable hospitalization in a Spanish region with high population dispersion. Eur J Public Health. 2013;23946–51. 10.1093/eurpub/cks163 . Diez Roux AV. Neighborhoods and Health: What Do We Know? What Should We Do? Am. J. Public Health . 2016;(106):430–431. https://search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=113090729&site=ehost-live&scope=site . Accessed on: 11 Feb 2024. Parikka S, Koskela T, Pietilä A, Koponen P, Koskinen S. THL:n sairastavuusindeksi 2019: Sairastavuuden alueittaiset erot ovat suuria. Tilastoraportti 13/2022. THL. https://www.julkari.fi/handle/10024/144327 . Accessed on: 11 Feb 2024. Tang Y, Ye J, Yang L, Ran L, Wu J. Concept analysis of perceived health from the perspective of rural adults in China. Int J Nurs Knowl. 2022;3393–9. 10.1111/2047-3095.12337 . Daker-White G, Hays R, McSharry J, Giles S, Cheraghi-Sohi S, Rhodes P, et al. Blame the Patient, Blame the Doctor or Blame the System? A Meta-Synthesis of Qualitative Studies of Patient Safety in Primary Care. PLoS ONE. 2015;10(8):e0128329. 10.1371/journal.pone.0128329 . Luo F, Zou P, Zhang H, Pang S. Exploration of village health centres in Northern and Central China: A qualitative study. Aust J Rural Health. 2020;28(3):271–80. 10.1111/ajr.12635 . Khalil H, Gruis H. Medication safety challenges in Aboriginal Health Care services. Aust J Rural Health. 2019;27(6):542–9. 10.1111/ajr.12554 . Gillespie U, Alassaad A, Henrohn D, Garmo H, Hammarlund-Udenaes M, Toss H, et al. A comprehensive pharmacist intervention to reduce morbidity in patients 80 years or older: A randomized controlled trial. Arch Intern Med. 2009;169(9):894–900. 10.1001/archinternmed.2009.71 . Verstappen W, Gaal S, Esmail A, Wensing M. Patient safety improvement programmes for primary care. Review of a Delphi procedure and pilot studies by the LINNEAUS collaboration on patient safety in primary care. Eur J Gen Pract. 2015;21(Suppl9513566):50–5. 10.3109/13814788.2015.1043725 . Weinhold I, Gurtner S. Understanding shortages of sufficient health care in rural areas. Health Policy. 2014;118(2):201–14. 10.1016/j.healthpol.2014.07.018 . Hall-Lipsy E, Anderson EJ, Taylor AM, Warholak T, Axon DR, Faqeeri Z, et al. Community health worker perspectives of an academic community medication therapy management collaboration. J Am Pharm Assoc. 2020;60(3):475–80. 10.1007/s13300-018-0373-9 . Passey D, Healy R, Qualls J, Hamilton CJ, Tilley E, Burningham Z, et al. Development and implementation of a pharmacist-led telehealth medication management program for veterans receiving oral antineoplastic therapies through the MISSION Act. Am J Health Syst Pharm. 2022;79(11):835–43. https://doi.org/10.1093/ajhp/zxac023 . Litke J, Spoutz L, Ahlstrom D, Perdew C, Llamas W, Erickson K. Impact of the clinical pharmacy specialist in telehealth primary care. Am J Health-Syst Pharm AJHP Off J Am Soc Health-Syst Pharm. 2018;75(13):982–6. 10.2146/ajhp170633 . Hogan KA, Lapenskie J, Leclair J, Thick N, Gazarin M, Webster P, et al. Implementing Safe Practices in Administering Pro re nata Medications in a Rural Hospital. J Patient Saf. 2019;15(4):302–4. https://doi.org/10.1097/PTS.0000000000000276 . Tong EY, Hua PU, Edwards G, Van Dyk E, Yip G, Mitra B, et al. Partnered pharmacist medication charting (PPMC) in regional and rural general medical patients. Aust J Rural Health. 2022;30(5):593–600. 10.1111/ajr.12895 . Gazarin M, Devin B, Tse D, Mulligan E, Naciuk M, Duncan S, et al. Evaluating an inpatient deprescribing initiative at a rural community hospital in Ontario. Can Pharm J. 2020;153(4):224–31. 10.1177/1715163520929734 . Sova PM, Holmström AR, Airaksinen M, Sneck S. Using Healthcare Failure Mode and Effect Analysis in prospective medication safety risk management in secondary care inpatient wards. Eur J Hosp Pharm . 2022; Oct 5:ejhpharm-2021-003109. 10.1136/ejhpharm-2021-003109 . Khalil H, Lee S. The implementation of a successful medication safety program in a primary care. J Eval Clin Pract. 2018;24(2):403–7. 10.1111/jep.12870 . Celikkayalar E, Myllyntausta M, Grissinger M, Airaksinen M. Adapting and remodelling the US Institute for Safe Medication Practices’ Medication Safety Self-Assessment tool for hospitals to be used to support national medication safety initiatives in Finland. Int J Pharm Pract. 2016;24(4):262–70. 10.1111/ijpp.12238 . Institute for Safe Medication Practices. ISMP Medication Safety Self Assessment for Hospitals. https://www.ismp.org/assessments/hospitals . Accessed on 21 May 2022. Institute for Safe Medication Practices Canada. Hospital Medication Safety Self-Assessment. 2016. https://mssa.ismp-canada.org/hospital . Accessed 1 Jun 2022. Kaufmann CP, Stämpfli D, Mory N, Hersberger KE, Lampert ML. Drug-Associated Risk Tool: Development and validation of a self-assessment questionnaire to screen for hospitalised patients at risk for drug-related problems. BMJ Open. 2018;8:e016610. 10.1136/bmjopen-2017-016610 . Tupper J, Coburn A, Loux S, Moscovice I, Klingner J, Wakefield M. Strategies for Improving Patient Safety in Small Rural Hospitals. In: Henriksen K, Battles JB, Keyes MA, editors. Advances in Patient Safety: New Directions and Alternative Approaches (Vol 2: Culture and Redesign). Rockville (MD). Agency for Healthcare Research and Quality (US). 2008;Aug. https://www-ncbi-nlm-nih-gov.libproxy.helsinki.fi/books/NBK43709/ . Accessed on 24 Aug 2022. Panesar SS, DeSilva D, Carson-Stevens A, Cresswell KM, Salvilla SA, Slight SP, et al. How safe is primary care? A systematic review. BMJ Qual Saf. 2016;25(7):544–53. 10.1136/bmjqs . Suvikas-Peltonen E, Granfors E, Celikkayalar E, Laaksonen R, Palmgren J, Airaksinen M. Development and content validation of an assessment tool for medicine compounding on hospital wards. Int J Clin Pharm. 2016;38:1457–63. 10.1007/s11096-016-0389-z . Ministry of Social Affairs and Health. Wellbeing services counties will be responsible for organising health, social and rescue services. 2023. https://stm.fi/en/wellbeing-services-counties . Accessed on 10 Nov 2023. Kangas O, Kalliomaa-Puha L. Finland finalises its largest-ever social and healthcare reform, ESPN Flash Report 2022/39. European Social Policy Network (ESPN), Brussels: European Commission. https://ec.europa.eu/social/BlobServlet?docId=25947&langId=en . Accessed on 26 Aug 2023. Valvira. Under a new act, all social and health care service providers must be registered. 2023. https://www.valvira.fi/web/en/-/under-a-new-act-all-social-and-health-care-service-providers-must-be-registered . Accessed on 26 Aug 20023. National institute for Health and Welfare. Statistical Yearbook on Social Welfare and Health Care. 2020. Vantaa: National Institute for Health and Welfare; 2021 p. 328. https://urn.fi/URN:ISBN:978-952-343-615-2 . Accessed on 5 Aug 2021. Lapin liitto. Information about Lapland. 2017. https://www.lapinliitto.fi/en/information/general-information-about-lapland/ . Accessed on 21 May 2022. Karhinen E. Selvitys sairaansijojen määrästä ja alueellisesta jakautumisesta Suomessa: Taustaselvitys rakennusinvestointien tarpeen arviointiin. Ministry of Social Affairs and Health Report 2020:36. Abstract available in English. http://urn.fi/URN:ISBN:978-952-00-8355-7 . Accessed on 7 Sep 2022. Hasson F, Keeney S, McKenna H. Research guidelines for the Delphi survey technique. J Adv Nurs. 2000;32(4):1008–15. 10.1046/j.1365-2648.2000.t01-1-01567.x . Okoli C, Pawlowski SD. The Delphi method as a research tool: an example, design considerations and applications. Inf Manage. 2004;42(1):15–29. Campbell SM, Cantrill JA. Consensus methods in prescribing research. J Clin Pharm Ther. 2001;26(1):5–14. 10.1111/J.1365-2710.2001.00331.X . Shang Z. Use of Delphi in health sciences research: A narrative review. Medicine. 2023;102(7):e32829. https://doi.org/10.1097/MD.0000000000032829 . Oksa E, Olin K, Airaksinen M, Celikkayalar E. Lääkitysturvallisuuden itsearviointi sairaalassa - itsearviointityökalun päivitys. Dosis . 2021;37(1):16–54. Abstract available in English. https://dosis.fi/wp-content/uploads/2021/03/016-055_Dosis_1-2021_Oksa_Olin.pdf . Accessed on 21 May 2022. Teinilä T, Halmepuro-Jaatinen S, Yritys K, Manni K, Airaksinen M. Adapting the US Institute for Safe Medication Practices’ Medication Safety Self Assessment tool for community pharmacies in Finland. Int J Pharm Pract. 2012;20(1):15–24. 10.1111/j.2042-7174.2011.00158.x . Taylor E. We Agree, Don’t We? The Delphi Method for Health Environments Research. Health Environ Res Des Journa. 2020;13(1):11–23. 10.1177/1937586719887709 . Laukkanen E, Ruokoniemi P, editors. Safe pharmacotherapy Guide to producing a pharmacotherapy plan. Helsinki: Ministry of Social Affairs and Health. Report 2021;6:1–116. Abstract available in English. http://urn.fi/URN:ISBN:978-952-00-8682-4 . Accessed on 2 Mar 2021. Agency for Healthcare Research. Hospital Survey on Patient Safety Culture Version 2.0. Agency for Healthcare Research. 2019. https://www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/SOPS-Hospital-Survey-2.0-5-26-2021.pdf . Accessed on 14 Feb 2021. Singla AK, Kitch BT, Weissman JS, Campbell EG. Assessing patient safety culture: A review and synthesis of the measurement tools. J Patient Saf. 2006;2(3):105–15. 10.1097/01.jps.0000235388.39149.5a . Clinical Excellence Commission. Medication Safety Self Assessment for Australian Hospitals. 2015. https://www.cec.health.nsw.gov.au/__data/assets/pdf_file/0011/326909/MSSA-Complete-Workbook-2015.pdf . Accessed on 6 Sep 2022. Murray M, Cope V, Leadership. Patient safety depends on it! Collegian. 2021;28(6):604–9. 10.1016/j.colegn.2021.07.004 . Künzle B, Kolbe M, Grote G. Ensuring patient safety through effective leadership behaviour: A literature review. Saf Sci. 2010;48(1):1–17. 10.1016/j.ssci.2009.06.004 . Chambers B, Fleming C, Packer A, Botha L, Hawthorn G, Nott S. Virtual clinical pharmacy services: A model of care to improve medication safety in rural and remote Australian health services. Am J Health Syst Pharm. 2022;79(16):1376–84. 10.1093/ajhp/zxac082 . Meyer-Massetti C, Cheng CM, Schwappach DLB, Paulsen L, Ide B, Meier CR, et al. Systematic review of medication safety assessment methods. Am J Health Syst Pharm. 2011;68(3):227–40. https://doi.org/10.2146/ajhp100019 . Finnish Nationa Board on Research Integrity Tenk, Advice, Materials. 2024. https://tenk.fi/en/advice-and-materials . Accessed on 29 May 2024. Supplementary File Appendix 1 is not available with this version. Appendix 1. Questionnaires Q1-Q4 Additional Declarations No competing interests reported. Supplementary Files PMSSAtoolPrimaryCarelehteen20240501.xlsx Appendix 2. PMSSA-tool. Cite Share Download PDF Status: Published Journal Publication published 07 Feb, 2025 Read the published version in BMC Primary Care → Version 1 posted Editorial decision: Revision requested 06 Jun, 2024 Submission checks completed at journal 03 Jun, 2024 Editor assigned by journal 03 Jun, 2024 First submitted to journal 02 Jun, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4518075","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":311172605,"identity":"c1321c37-ee04-4e9d-a60e-166d8c5cc463","order_by":0,"name":"Päivi Sova","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5ElEQVRIiWNgGAWjYFACxgaGBDCD+eABBoYDILqBWC1sCRAtbImEtMABjwFUSwJ+debsh9skHjDUyRkcP/PhwM8dd+QZ2Jjx22LZk9gmkcBw2NjgTO6Gg71nnhk2sDHi12JwILHZIIHhQOLMhtwNB3jbDjM2yDcS0HL+IUhLXeLM/jcPDv5tO2xP2JYbiY0PEhiYE/slchgOA21JJKjFcsZDoBaDw8b8Es8MDsueOZzcRkiLOX/6g4M/Kurk2PiTHz58u+OwbT8b+wP8DkMiwdHKwIZXPZJihJZRMApGwSgYBegAAGrAUBFSzRxvAAAAAElFTkSuQmCC","orcid":"","institution":"Wellbeing Services County of Lapland","correspondingAuthor":true,"prefix":"","firstName":"Päivi","middleName":"","lastName":"Sova","suffix":""},{"id":311172606,"identity":"bea64237-4660-4772-933b-ba98840eec0d","order_by":1,"name":"Ercan Celikkayalar","email":"","orcid":"","institution":"Wellbeing Services County of Kanta-Häme","correspondingAuthor":false,"prefix":"","firstName":"Ercan","middleName":"","lastName":"Celikkayalar","suffix":""},{"id":311172607,"identity":"fc49e4a0-8499-44f6-8fb6-3b01983f94a2","order_by":2,"name":"Sami Sneck","email":"","orcid":"","institution":"Oulu University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Sami","middleName":"","lastName":"Sneck","suffix":""},{"id":311172608,"identity":"466cf7f8-8e73-4f4b-bbd6-f36afc54d4a9","order_by":3,"name":"Anna-Riia Holmström","email":"","orcid":"","institution":"University of Helsinki","correspondingAuthor":false,"prefix":"","firstName":"Anna-Riia","middleName":"","lastName":"Holmström","suffix":""}],"badges":[],"createdAt":"2024-06-02 18:42:54","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4518075/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4518075/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12875-025-02722-3","type":"published","date":"2025-02-07T15:58:10+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":58747019,"identity":"1878a19d-8793-429d-b574-119ff71ce95b","added_by":"auto","created_at":"2024-06-20 15:12:37","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":290669,"visible":true,"origin":"","legend":"\u003cp\u003eHealthcare units with and without a local hospital pharmacy in Finnish Lapland.\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4518075/v1/10b5c02211870c41acab868c.jpg"},{"id":58747023,"identity":"49733409-89cd-4a5a-bd7e-90738efa3d95","added_by":"auto","created_at":"2024-06-20 15:12:37","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":319443,"visible":true,"origin":"","legend":"\u003cp\u003ePhase I of the study: developing the Delphi instrument.\u003c/p\u003e","description":"","filename":"Figure2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4518075/v1/82deb3351a9d1bda4c0d8849.jpeg"},{"id":58747020,"identity":"822cc838-e86d-47ec-9cf5-d9d067e98d38","added_by":"auto","created_at":"2024-06-20 15:12:37","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":250556,"visible":true,"origin":"","legend":"\u003cp\u003eResearch procedure to develop a PMSSA tool for the rural Lapland of Finland. In Phase I, three medication safety tools were used to create the statements for Delphi questionnaires (Q1-6) administered in Phase II. The excluded statements are presented in red, and the included ones in green. * The statements for which a panel consensus (either statement exclusion or inclusion) was reached.\u003c/p\u003e\n\u003cp\u003e* The statements for which a panel consensus (either statement exclusion or inclusion) was reached.\u003c/p\u003e","description":"","filename":"Figure3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4518075/v1/47c77af61086696f67e2c64e.jpeg"},{"id":75930520,"identity":"3dbfac49-cdde-42dd-a057-bbe694f6bf51","added_by":"auto","created_at":"2025-02-10 16:12:47","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1831956,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4518075/v1/fd7c5060-00ed-4b7b-8c67-465aead684ef.pdf"},{"id":58747017,"identity":"7becc834-d628-411f-8aa5-8e1995978427","added_by":"auto","created_at":"2024-06-20 15:12:36","extension":"xlsx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":33908,"visible":true,"origin":"","legend":"\u003cp\u003eAppendix 2. PMSSA-tool.\u003c/p\u003e","description":"","filename":"PMSSAtoolPrimaryCarelehteen20240501.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-4518075/v1/f4ce6cc75677b8a7fe6c41bb.xlsx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Developing a medication-safety self-assessment tool for rural primary care units - A case from Finnish Lapland","fulltext":[{"header":"1. Background","content":"\u003cp\u003eMedication errors, described as any preventable event that may cause or lead to inappropriate medication use or patient harm [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], are among the most commonly reported adverse incidents in European healthcare [\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhile several studies have aimed to promote systems-based medication safety in hospitals, less emphasis has been placed on proactive medication risk management in primary care settings, especially in rural area hospitals [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In rural areas, the population is often older and tends to suffer more from chronic diseases than do residents of non-urban regions [\u003cspan additionalcitationids=\"CR7 CR8 CR9\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Consequently, rural primary care has unique challenges, often involving complex medical cases and limited resources [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan additionalcitationids=\"CR12 CR13 CR14 CR15 CR16\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. To tackle these problems, previous studies have suggested various approaches, such as strengthening multi-professional collaboration [\u003cspan additionalcitationids=\"CR19 CR20 CR21 CR22\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], establishing remote pharmacy services [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], and developing public health programs aiming at medication process evaluation and enhanced safety of care providers [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. To systematically control the risks associated with the medication process, rural primary care units could benefit from introducing proactive approaches, such as medication safety self-assessment (MSSA), to uncover the central risk points of care [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMSSA tools have been adopted for medication risk management in healthcare systems of different countries [\u003cspan additionalcitationids=\"CR27 CR28\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. They use a systematic, collaborative process to evaluate the unit's medication safety guidelines and practices under investigation. However, current MSSA tools focus mainly on the issues of large hospitals and complex tertiary care [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan additionalcitationids=\"CR31\" citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], while MSSA tools with targeted primary care criteria have not yet been developed. Due to varying risk profiles in different care environments [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], current MSSA tools may not provide an optimal risk assessment strategy for small rural hospitals with limited resources. In rural areas, such as Finnish Lapland, a key deficiency is often the experienced lack of pharmacy professionals in local primary care settings. Therefore, identifying medication safety risks may need to rely more on the contribution of other available local healthcare professionals, with remote pharmacy services being supportive.\u003c/p\u003e \u003cp\u003eAn MSSA tool targeted for medication risk management of rural primary care units would need to encompass the before-mentioned special features of the respective environment. However, to our knowledge, no such adopted MSSA tools currently exist. Using Finnish Lapland as a case example, this study aimed to develop a comprehensive yet practical MSSA tool for rural primary care settings (PMSSA) with limited resources to ensure safe local medication processes.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cp\u003e \u003cb\u003eStudy context\u003c/b\u003e \u003c/p\u003e \u003cp\u003eIn 2023, Finland established a nationwide public healthcare reform [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e], creating 21 wellbeing services counties as service organizers and providers. A central goal of the reform was to ensure equal services and to reduce regional health and well-being inequalities among Finnish citizens. By law, the well-being service counties are responsible for self-monitoring produced services. Therefore, the counties must prepare an electronic self-monitoring plan concerning quality control, risk management, and patient safety[\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe present study was conducted in the rural Lapland area of Finland. The Lapland Wellbeing Services County is responsible for offering health and social services to its inhabitants. Lapland is Finland\u0026rsquo;s largest and northernmost area (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The area of the Lapland region is 100,367 km\u003csup\u003e2\u003c/sup\u003e with a population density of 1.9 people/km\u003csup\u003e2\u003c/sup\u003e, and 25% of the population is over 65 years old and has a high rate of chronic diseases [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. There are two special care hospitals in Lapland Wellbeing Services County, whereas primary care services are produced in 21 units within the area, with 630 inpatient beds [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Altogether, six hospital pharmacies support the healthcare units (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), but most primary care units in Lapland lack comprehensive hospital pharmacy services due to long distances.\u003c/p\u003e \u003cp\u003eConsequently, pharmacy services provided for the primary care units are mainly remote services far from the primary care unit (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Typical remote services include overnight delivery of medicines and clinical pharmacy services offered by phone, such as information on intravenous medication administration incompatibles and instructions for using new medicines. Pharmacy services related to long-term medication risk management, medicine handling, and appropriateness of medication-related facilities are inadequate. Improving medication safety through self-monitoring in rural Lapland would require new techniques, such as PMSSA, independent of local hospital pharmacy services.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eDelphi consensus method\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThis study used the Delphi method to develop a PMSSA tool for rural Lapland. The Delphi technique is a multistage process for deriving consensus among separate experts [\u003cspan additionalcitationids=\"CR40 CR41\" citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e], and it has been previously used in developing MSSA tools for various healthcare settings [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. The method effectively allows a group of individuals to deal with complex problems based on principles of anonymity, iteration, and feedback [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. The anonymity of the answers will enable individuals to freely express their thoughts and ideas without fearing judgment. The present study used the eDelphi software, allowing the researchers to observe whether the individual panelists had entered the questionnaire platform. This enabled the monitoring of participation activity and kept all panelists involved until the end of the study.\u003c/p\u003e \u003cp\u003eThe present study comprised three phases, including two Delphi rounds with six questionnaires (Q1-6). The Delphi questionnaires with instructions were emailed to the panelists between December 2021 and April 2022. After two weeks, the link for each questionnaire was resent, and panelists who had not yet answered were personally reminded. Each questionnaire was kept open until all panelists delivered their responses, and the following questionnaire was released. A descriptive quantitative analysis with numbers and percentages was conducted using MS Excel by the main researcher (PS).\u003c/p\u003e \u003cp\u003e \u003cb\u003eDelphi panelists\u003c/b\u003e \u003c/p\u003e \u003cp\u003eA convenience sample of individuals (n\u0026thinsp;=\u0026thinsp;12) identified as primary care and patient safety experts in the Lapland area were contacted by phone and asked to participate in the study in November 2021. After the contacts, the study's introductory written material was emailed to the experts to confirm their participation. In total, 10 panelists agreed to participate. The group was further strengthened with two additional experts from the Finnish Center for Client and Patient Safety to provide a national perspective for developing a specific region-based risk management tool. The final Delphi panel (n\u0026thinsp;=\u0026thinsp;12 experts) consisted of four nurses, five pharmacists, and three physicians.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePhase I: Developing the Delphi instrument\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThree existing proactive risk management tools were identified to develop the Delphi instrument (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The first tool was a recently updated MSSA tool targeted at Finnish hospitals [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. The tool originates from the Institute for Safe Medication Practices (ISMP) MSSA tool[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], which was adapted to the Finnish healthcare environment in 2016 [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe second source was the National Guideline for Safe Medication Management and Use in Finland [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. The guideline recommends that Finnish care units (e.g., hospital wards and nursing homes) develop internal protocols for safe medication practices. The third tool was the Hospital Survey on Patient Safety Culture by the Agency for Healthcare Research and Quality [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]; patient safety culture assessment tools are recommended to be used as part of the regular safety assessment in hospitals [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eTo develop the Delphi instrument, the contents of the three selected risk management tools were combined to form statements. The statements (n\u0026thinsp;=\u0026thinsp;436) were further formatted by the study group members (PS, EC, SS, A-RH), who had clinical and academic expertise in proactive medication risk management. As a part of the process, the statements were formatted into the same configuration, favoring a positive approach, e.g., the statement: \u003cem\u003e\u0026ldquo;In this unit, there is a lack of support for staff involved in patient safety errors\u0026rdquo;\u003c/em\u003e was formatted to \u003cem\u003e\u0026ldquo;There is enough support for staff involved in patient safety errors\u0026rdquo;.\u003c/em\u003e Additionally, statements concerning specialized health care were irrelevant to rural primary care in Lapland and removed (e.g., central anaesthesia). Statements from different sources with similar meanings were integrated to form one statement. E.g., the following individual statements were integrated into one statement: \u0026ldquo;\u003cem\u003eAn employee\u0026rsquo;s competence in pharmacotherapy is verified in the manner defined in the unit\u0026rsquo;s safe medication management and use protocol before the employee can start implementing pharmacotherapy independently for the patients\u0026rdquo;\u003c/em\u003e and \u0026ldquo;\u003cem\u003eAll new employees and substitutes involved in the medication process are assessed for competency before they begin independent work. The authorization to work independently is given in writing. It is part of the orientation documentation of the employee\u003c/em\u003e\u0026rdquo;. The new single statement was: \u0026ldquo;\u003cem\u003eThe qualifications of all new employees and substitutes (including doctors and nurses) participating in pharmacotherapy are assessed in the manner defined in the unit-based safe medication management and use protocol before they start working independently. The authorization to work independently is given in writing and is part of the orientation documentation\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e \u003cp\u003eAfter formatting, the study group identified the following main themes among the statements: 1. Leadership, 2. Personnel and actions in hazard incidents, 3. Environment, equipment and software, and 4. Medication process (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). A separate questionnaire was formed for each theme, and four patient safety and primary care experts were invited to validate the questionnaires as pre-Delphi. Based on the pre-Delphi, one statement was clarified, and a six-step evaluation scale of the statements was altered into a four-step scale (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cb\u003eDelphi round 1\u003c/b\u003e \u003c/p\u003e \u003cp\u003eIn the first Delphi round, four questionnaires (Q1-4), each representing one of the four themes, were administered to the panelists (Appendix 1). The panelists evaluated each statement based on its importance to medication safety and the primary care environment by using a four-step scale (- / + / ++ / +++), in which \u0026ldquo;-\u0026ldquo; represented \u0026ldquo;not important at all\u0026rdquo; and \u0026ldquo;+++\u0026rdquo; represented \u0026ldquo;highly important\u0026rdquo;. The practicality of the PMSSA tool to be developed was emphasized to the panelists, meaning the tool should be comprehensive but concise enough to be used in small primary care units. The final tool should also exclude self-evident or otherwise unnecessary statements inappropriate to primary care settings. Consequently, the panelists were asked to be critical in their evaluation of the statements. The panelists were also invited to suggest alterations or new statements and provide relevant comments. All comments by the panelists were anonymous but visible, and the panelists could comment on each other\u0026rsquo;s notions during the Delphi round.\u003c/p\u003e \u003cp\u003eDuring the analysis, answers - and +\u0026thinsp;were combined into one category of \u0026ldquo;not sufficiently important or essential\u0026rdquo; to achieve a concise PMSSA tool concentrating on the most pertinent prioritized statements. Correspondingly, answers\u0026thinsp;+\u0026thinsp;+\u0026thinsp;and +++ were categorized as \u0026ldquo;sufficiently important and essential\u0026rdquo;. On the first Delphi round, if\u0026thinsp;\u0026ge;\u0026thinsp;50% of the panelists had indicated an individual statement as \u0026ldquo;not sufficiently important or essential\u0026rdquo;, the statement was excluded from the PMSSA tool. The statements with a consensus of \u0026ge;\u0026thinsp;85% on being \u0026ldquo;sufficiently important and essential\u0026rdquo; were included directly in the PMSSA tool. The representative consensus limits were chosen to identify the most critical issues to be evaluated in the PMSSA tool without becoming too broad for practice. Statements which did not reach consensus during the first Delphi round were re-evaluated in the second Delphi round.\u003c/p\u003e \u003cp\u003e \u003cb\u003eDelphi round 2\u003c/b\u003e \u003c/p\u003e \u003cp\u003eBefore administering the second Delphi, the statements were altered based on panelists\u0026rsquo; comments from the first Delphi round. To facilitate ease of answering, four themes were combined into the following two questionnaires: Leadership, personnel and actions in hazard incidents (Q5), and Environment, equipment, software and medication process (Q6). The panelists were also provided access to statements already included in the PMSSA tool, comments made in the first round, and the original statement if the statement was re-formatted. In the second round, the panelists were asked to evaluate the necessity of the statement to be included in the PMSSA tool on a scale of yes/no. Similarly, as in the first round, the Delphi panel could suggest alterations or new statements or provide other comments; all comments were anonymous but visible to all panelists during the questionnaire. The statements with a consensus of \u0026gt;\u0026thinsp;50% were included or excluded from the PMSSA tool. The study group evaluated statements with a precisely 50% level of agreement to decide whether to include or exclude them; the decision was based on the panelists\u0026rsquo; comments, previously included statements, and study group evaluation.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePhase III: Developing the PMSSA tool\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe study group developed the final PMSSA tool based on the statements included in the Delphi process (Fig.\u0026nbsp;3). The PMSSA tool was developed by re-grouping the included statements into smaller sub-groups based on the previously developed Finnish MSSA tool for secondary care settings [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e] and adding a scale of evaluation for each statement. Also, user instructions were provided in the final tool.\u003c/p\u003e "},{"header":"3. Results","content":"\u003cp\u003e All agreed panelists (100%, n\u0026thinsp;=\u0026thinsp;12) participated in all Delphi questionnaires (Q1-6) during the two Delphi rounds. The average response rate to the statements (n\u0026thinsp;=\u0026thinsp;471) of the questionnaires was 93%. The lowest response rate to single statements was 75%, concerning nine out of 471 statements. The results of the present study comprise the consensus reached in the two Delphi rounds, the description of the panelists\u0026rsquo; comments during the rounds, and the final PMSSA tool developed based on the included statements.\u003c/p\u003e \u003cp\u003e \u003cb\u003eThe reached consensus, and the panelists\u0026rsquo; comments\u003c/b\u003e \u003c/p\u003e \u003cp\u003eIn the first Delphi round (Q1-4), a consensus was reached on 118 out of 304 statements (39%), of which 86% were included, and 14% were excluded from the final PMSSA tool. During the first Delphi round, the panelists (n\u0026thinsp;=\u0026thinsp;12) provided 198 comments to the statements (n\u0026thinsp;=\u0026thinsp;304) of the administered questionnaires (Q1-4) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Based on the comments, 25 statements were altered, one statement was added, and 20 were combined with another statement due to similarities. In the second round (Q5-6), 141 out of 167 statements (84%) reached a consensus, of which 70% were excluded and 30% included in the final PMSSA tool. The consensus percentages varied between 32%-46% for the first round of Delphi questionnaires (Q1-4), while consensus percentages of 77% and 90% were achieved for the questionnaires (Q5-6) in the second round (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe number and types of comments provided for each questionnaire (Q1-6) by the panelists (n\u0026thinsp;=\u0026thinsp;12) during the Delphi rounds.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSuggestions for new statements (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSuggestions for content alterations (n\u0026thinsp;=\u0026thinsp;31)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSupporting opinions for inclusion\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;34)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSupporting opinions for exclusion\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;65)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eOther comments\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;82)*\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eIn total\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;213)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRound 1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eQ1\u003c/b\u003e: Leadership\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e69\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eQ2\u003c/b\u003e: Personnel and\u003c/p\u003e \u003cp\u003eaction in hazard \u003c/p\u003e \u003cp\u003eincidents\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e58\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eQ3\u003c/b\u003e: Environment, Equipment and \u003c/p\u003e \u003cp\u003eSoftware\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eQ4\u003c/b\u003e: Medication \u003c/p\u003e \u003cp\u003eprocess\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal/round 1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e198\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRound 2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eQ5\u003c/b\u003e: Leadership, \u003c/p\u003e \u003cp\u003epersonnel and action in hazard incidents\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eQ6\u003c/b\u003e: Environment, Equipment, Software and Medication \u003c/p\u003e \u003cp\u003eprocess\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal/round 2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e*Non-relevant content for formatting, adding, including or excluding the statements.\u003c/p\u003e \u003cp\u003eDuring the second Delphi round, the panelists provided 15 comments to the statements (n\u0026thinsp;=\u0026thinsp;167) in both administered questionnaires (Q5-6) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), with the majority (n\u0026thinsp;=\u0026thinsp;9) concerning supporting opinions for the exclusion of statements. There were no suggestions for new statements. Consequently, the statements for which the consensus was reached (Figs.\u0026nbsp;3 and Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) were included or excluded from the final PMSSA tool without any changes.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe number of included and excluded statements, the level of the achieved consensus for each Delphi questionnaire (Q1-6), and the results of study group evaluation between the Delphi rounds.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQ1: Leadership (n\u0026thinsp;=\u0026thinsp;71)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQ2: Personnel and action in hazard incidents (n\u0026thinsp;=\u0026thinsp;58)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eQ3: Environment, equipment, and software (n\u0026thinsp;=\u0026thinsp;60)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eQ4: Medication process (n\u0026thinsp;=\u0026thinsp;115)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eDelphi round I*\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncluded\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExcluded\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLevel of achieved consensus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e37%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFormatting, adding, and combining statements by the study group\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFormatted\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdded\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCombined\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003eQ5: Leadership, personnel, and action in hazard incidents (n\u0026thinsp;=\u0026thinsp;75)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003eQ6: \u003cb\u003eEnvironment, equipment, software, and Medication process (n\u0026thinsp;=\u0026thinsp;92)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDelphi round II**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncluded\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExcluded\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003e58\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLevel of achieved consensus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e77%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003e90%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e*The required consensus rate was \u0026ge;\u0026thinsp;50% for excluding and \u0026ge;\u0026thinsp;85% for including a statement on the first Delphi round; **the required consensus rate was \u0026gt;\u0026thinsp;50% for including and excluding a statement on the second Delphi round.\u003c/p\u003e \u003cp\u003e \u003cb\u003eThe final PMSSA tool\u003c/b\u003e \u003c/p\u003e \u003cp\u003eIn total, 148 statements were included after Delphi rounds. However, when forming the final PMSSA tool (Appendix 2), the study group combined four statements which were considered similar. The included statements were further classified based on the ISMP MSSA tool for hospitals [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] with some alterations. \u0026ldquo;Quality, processes and risk management\u0026rdquo; was divided into two sections: \u0026ldquo;Proactive risk management\u0026rdquo; and \u0026ldquo;Learning from medication safety incidents\u0026rdquo; to increase practicality. In addition, a section for \u0026ldquo;Risk management supporting features of electronic medication record software\u0026rdquo; was added. Thus, in the final PMMS tool (Appendix 2), the approved statements (n\u0026thinsp;=\u0026thinsp;144, Fig.\u0026nbsp;3) were divided into the following twelve thematic sub-groups (n of statements per sub-group provided in brackets): 1. Patient information (n\u0026thinsp;=\u0026thinsp;9), 2. Drug information (n\u0026thinsp;=\u0026thinsp;10), 3. Communication (n\u0026thinsp;=\u0026thinsp;19), 4. Drug labeling, packaging and nomenclature (n\u0026thinsp;=\u0026thinsp;6), 5. Drug storage and distribution (n\u0026thinsp;=\u0026thinsp;11), 6. Medication device acquisition and use (n\u0026thinsp;=\u0026thinsp;7), 7. Environmental factors, workflow and staffing patterns (n\u0026thinsp;=\u0026thinsp;13), 8. Staff competency and education (n\u0026thinsp;=\u0026thinsp;15), 9. Patient education (n\u0026thinsp;=\u0026thinsp;10), 10. Quality control and risk management (n\u0026thinsp;=\u0026thinsp;18), 11. Learning from medication safety incidents (n\u0026thinsp;=\u0026thinsp;18), and 12. Risk management supporting features of electronic medication record software (n\u0026thinsp;=\u0026thinsp;8). An evaluation scale was adopted for the PMSSA tool from the Medication Safety Self-Assessment Tool for Hospitals in Finland [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. In the final PMSSA tool, each statement is evaluated on a four-level scale for the existing part of the instructions and the level of implementation (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe measuring scales of the statements (i.e., procedures to enhance medication safety) in the final PMSSA tool (Appendix 2).*\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eScale for availability of instructions on procedures\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eScale for implementation of procedures\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDescription\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eScale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDescription\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComprehensively instructed.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe procedure described in the statement has been fully guided, and all the staff have become familiar with the instructions and internalized their content. Orientation is documented for the whole staff (e.g., with reading receipts).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUsed comprehensively\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eThe procedure described in the statement is followed in every situation in the unit, and the entire staff follows it.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePartially instructed.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe procedure described in the statement is outlined in the unit. However, the instructions are insufficient to allow staff to follow the procedure described. The entire staff is not familiar with the instructions. The orientation documentation has been partially completed.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePartially used\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eThe procedure described in the statement is followed occasionally in certain situations, and/or some of the staff follow the procedure.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot instructed.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe procedure described in the statement has not been instructed at all in the unit, although it should be.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNot in use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eThe procedure described in the statement is not in use at all in the unit, although it should be.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe procedure described in the statement does not apply to the unit\u0026rsquo;s operation.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eThe procedure described in the statement does not apply to the unit\u0026rsquo;s operation.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e* Adopted from the Medication Safety Self-Assessment Tool for Hospitals in Finland [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e] and modified by the study group.\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eA committed inter-professional panel of medication and patient safety experts contributed to this Delphi study, enabling the development of a self-assessment tool for evaluating medication safety in rural primary care settings in Lapland. To our knowledge, this is the first study to introduce a medication risk management tool focusing on the specific needs of a particular setting of a demographically demanding area.\u003c/p\u003e \u003cp\u003eSeveral other MSSA tools concerning medication safety in different environments have been developed internationally and in Finland over the past years [\u003cspan additionalcitationids=\"CR27\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. The present tool represents a continuation of the previous MSSA tools for hospitals [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e], which have been well received and adopted as a part of national medication safety guidelines in Finland [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. In this PMSSA tool, similar thematic sub-groups were formed as in the previous Finnish MSSA tool for hospitals, but in the new primary care-focused tool, the priorities and contents differed from the previous secondary care-focused tools.\u003c/p\u003e \u003cp\u003eThe final PMSSA tool consists of 144 statements, less than in many other national and international MSSA tools [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. Compared to the previous secondary care-focused Finnish MSSA tool [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e], the number of statements remained almost the same in the \u0026lsquo;Patient Information and Communication\u0026rsquo; sub-groups. This indicates that establishing procedures for safe handling of patient information and effective means of communication are equally important in both secondary and primary care. The number of statements in sub-groups \u0026ldquo;The medication device acquisition and use\u0026rdquo; and \u0026ldquo;Drug storage and distribution\u0026rdquo; was significantly less than in the previous Finnish MSSA tool. This may result from having fewer medication treatment-related devices, complex medication treatments, or high-risk administration routes in primary care, reducing their potential for confusion. No sub-group of PMSSA tool received more statements than the previous MSSA tool.\u003c/p\u003e \u003cp\u003eBased on the expert evaluation during the first Delphi round of the study, the highest degree of consensus was reached on the leadership-related statements. Indeed, leadership is one of the most critical factors affecting organizations\u0026rsquo; ability to adopt medication safety practices across types of healthcare organizations [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. In contrast, the smallest consensus during the first Delpihi round was reached on the theme of \u0026ldquo;Environment, equipment, and software\u0026rdquo;. This could reflect that the health units' seek independence in choosing their working tools and software, potentially representing a reason why the experts' assessments of their importance to patient safety varied.\u003c/p\u003e \u003cp\u003eWhile there are indications that the quality of healthcare in rural areas of Finland may lag behind the development of the rest of the country [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], understanding patient safety concepts and building a patient safety culture in rural Lapland remains a central target for public health development, to which the present tool aims to contribute. Similarly to in other rural areas, the healthcare system in Lapland uses many remote connections, which should be considered when developing functioning procedures for medication safety [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. The present PMSSA tool can be used to provide the primary care units with the possibility to independently identify their most critical areas for improvement without the demand for a direct onsite contribution from pharmacy professionals. However, in the case of Lapland, we recommend that the pharmacies still coordinate the self-assessment in healthcare units, which could be completed by the units at least before their annual remote audition. Consequently, pharmacy professionals can focus on supporting the units in managing the most critical and complex medication safety risks during the audits.\u003c/p\u003e \u003cp\u003e \u003cb\u003eLimitations and recommendations\u003c/b\u003e \u003c/p\u003e \u003cp\u003eDelphi is a subjective evaluation method; its reliability is affected by the choice of experts, i.e., the number and quality of panelists [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. While panels of 10\u0026ndash;23 experts are generally considered sufficient [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e], it was considered essential to keep all the panelists (n\u0026thinsp;=\u0026thinsp;12) involved in all questionnaires (Q\u0026thinsp;=\u0026thinsp;1\u0026ndash;6). To ensure the participation of all panelists, statements with consensus on the first Delphi round did not go through the second round iteration. Therefore, to control the bias, the first-round consensus rate was set high. Additionally, the researcher\u0026rsquo;s influence was minimized by setting the consensus limit of the second round so that only statements with which exactly half of the panelists disagreed remained for the researchers to evaluate [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe PMSSA is recommended to be adopted as a part of regular organization-level self-monitoring of care quality and a means for information-based management of health services. In the future, the PMSSA tool should be evaluated as to whether it is compact but comprehensive enough to fulfil its purpose. Also, the PMSSA tool has a potential to be transferable to sparsely populated, technically developed regions of primary care services in other countries. However, the tool should be validated to suit the local regulations, policies, and cultural dimensions that affect risk management practices [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e].\u003c/p\u003e"},{"header":"5. Conclusions","content":"\u003cp\u003eThe present study introduces a PMSSA tool developed for rural primary care units to support their proactive medication risk management. A consensus of a committed expert group was achieved on the contents of the PMSSA tool. While remote pharmacy services, distinct to rural areas, emphasizes the importance of self-assessment by units, pharmacy support is still recommended to manage the assessment and related risk management development activities of the units. In the future, the adoption of the tool should be validated to suit risk management practices in different rural primary care environments in different countries.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003ePMSSA Primary Care Medication Safety Self-Assessment\u003cp\u003e\n\u003cp\u003eMSSA Medication Safety Self-Assessment\u003c/p\u003e\n\u003cp\u003eISMP Institute for Safe Medication Practices\u003c/p\u003e\n"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eNot applicable. A study approval was obtained from the Lapland Central Hospital. A separate ethics committee approval was not sought as the study contained no patients or patient information.\u0026nbsp;The study was carried out in accordance with the National Research Ethics Guidelines and Regulations (Finnish Advisory Board on Research Integrity.\u0026nbsp;Responsible conduct in research and procedures for handling allegations of misconduct in Finland [54].\u003c/p\u003e\n\u003cp\u003eA written consent was obtained from all participants.\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eMaterials described in the manuscript, including all relevant raw data, are available from the corresponding author PS to any scientist wishing to use them for non-commercial purposes.\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflict of interest.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003eAuthors\u0026rsquo; contributions\u003c/p\u003e\n\u003cp\u003eEach manuscript author (PS, EC, SS and AH),has contributed to the study\u0026rsquo;s planning, conducting and reporting.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank the Delphi panelists for their valuable contributions to this study, pre-Delphi participants, and Professor Marja Airaksinen for participating in the commencement of the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSupplementary information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAppendix 1. Questionnaires Q1-Q4\u003c/p\u003e\n\u003cp\u003eAppendix 2. PMSSA-tool.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWeingart SN, Wilson RM, Gibberd RW, Harrison B. Epidemiology of medical error. Br Med J. 2000;320(3):774\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/ewjm.172.6.390\u003c/span\u003e\u003cspan address=\"10.1136/ewjm.172.6.390\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWHO. Patient safety - Data and statistics. 2021. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.euro.who.int/en/health-topics/Health-systems/patient-safety/data-and-statistics\u003c/span\u003e\u003cspan address=\"https://www.euro.who.int/en/health-topics/Health-systems/patient-safety/data-and-statistics\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCouncil of Europe. Creation of a better medication safety culture in Europe: Building up safe medication practices. Council of Europe. 2007. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://optimiz-sih-circ-med.fr/Documents/Council_of_Europe_Medication_Safety_Report_19-03-2007.pdf\u003c/span\u003e\u003cspan address=\"http://optimiz-sih-circ-med.fr/Documents/Council_of_Europe_Medication_Safety_Report_19-03-2007.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed on 14 Feb 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWHO. Medication Without Harm - Global Patient Safety Challenge on Medication Safety. Geneva: WHO. 2017 p. 16. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://iris.who.int/bitstream/handle/10665/255263/WHO-HIS-SDS-2017.6-eng.pdf?sequence=1\u003c/span\u003e\u003cspan address=\"https://iris.who.int/bitstream/handle/10665/255263/WHO-HIS-SDS-2017.6-eng.pdf?sequence=1\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed on 7 Mar 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGrativol MS, Mendes Junior WV. Patient safety in primary health care: a systematic review. Cad Sa\u0026uacute;de Publica. 2014;30(9):1815\u0026ndash;35. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1590/0102-311X00114113\u003c/span\u003e\u003cspan address=\"10.1590/0102-311X00114113\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAmerican Hospital Association, American Society of Health-System Pharmacists, Hospitals \u0026amp; Health Networks. Medication Safety Issue Brief. Small and rural hospitals\u0026ndash;unique challenges, unique solutions. Hosp Health Netw. 2005;79(11):45\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://pubmed.ncbi.nlm.nih.gov/16396133/\u003c/span\u003e\u003cspan address=\"https://pubmed.ncbi.nlm.nih.gov/16396133/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed on 24 Aug 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSatokangas M. Geographic equity in primary health care performance in Finland: from individual socioeconomic position into the blind spot of the service system. Helsinki: University of Helsinki, Faculty of Medicine; 2021 p. 1\u0026ndash;84. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://hdl.handle.net/10138/334486\u003c/span\u003e\u003cspan address=\"http://hdl.handle.net/10138/334486\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed on: 1 Jun 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBorda-Olivas A, Fern\u0026aacute;ndez-Navarro P, Otero-Garc\u0026iacute;a L, Sanz-Barbero B. Rurality and avoidable hospitalization in a Spanish region with high population dispersion. Eur J Public Health. 2013;23946\u0026ndash;51. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/eurpub/cks163\u003c/span\u003e\u003cspan address=\"10.1093/eurpub/cks163\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDiez Roux AV. Neighborhoods and Health: What Do We Know? What Should We Do? \u003cem\u003eAm. J. Public Health\u003c/em\u003e. 2016;(106):430\u0026ndash;431. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://search.ebscohost.com/login.aspx?direct=true\u0026amp;db=a9h\u0026amp;AN=113090729\u0026amp;site=ehost-live\u0026amp;scope=site\u003c/span\u003e\u003cspan address=\"https://search.ebscohost.com/login.aspx?direct=true\u0026amp;db=a9h\u0026amp;AN=113090729\u0026amp;site=ehost-live\u0026amp;scope=site\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed on: 11 Feb 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eParikka S, Koskela T, Pietil\u0026auml; A, Koponen P, Koskinen S. THL:n sairastavuusindeksi 2019: Sairastavuuden alueittaiset erot ovat suuria. Tilastoraportti 13/2022. THL. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.julkari.fi/handle/10024/144327\u003c/span\u003e\u003cspan address=\"https://www.julkari.fi/handle/10024/144327\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed on: 11 Feb 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTang Y, Ye J, Yang L, Ran L, Wu J. Concept analysis of perceived health from the perspective of rural adults in China. Int J Nurs Knowl. 2022;3393\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/2047-3095.12337\u003c/span\u003e\u003cspan address=\"10.1111/2047-3095.12337\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDaker-White G, Hays R, McSharry J, Giles S, Cheraghi-Sohi S, Rhodes P, et al. Blame the Patient, Blame the Doctor or Blame the System? A Meta-Synthesis of Qualitative Studies of Patient Safety in Primary Care. PLoS ONE. 2015;10(8):e0128329. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1371/journal.pone.0128329\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0128329\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLuo F, Zou P, Zhang H, Pang S. Exploration of village health centres in Northern and Central China: A qualitative study. Aust J Rural Health. 2020;28(3):271\u0026ndash;80. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/ajr.12635\u003c/span\u003e\u003cspan address=\"10.1111/ajr.12635\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhalil H, Gruis H. Medication safety challenges in Aboriginal Health Care services. Aust J Rural Health. 2019;27(6):542\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/ajr.12554\u003c/span\u003e\u003cspan address=\"10.1111/ajr.12554\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGillespie U, Alassaad A, Henrohn D, Garmo H, Hammarlund-Udenaes M, Toss H, et al. A comprehensive pharmacist intervention to reduce morbidity in patients 80 years or older: A randomized controlled trial. Arch Intern Med. 2009;169(9):894\u0026ndash;900. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1001/archinternmed.2009.71\u003c/span\u003e\u003cspan address=\"10.1001/archinternmed.2009.71\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVerstappen W, Gaal S, Esmail A, Wensing M. Patient safety improvement programmes for primary care. Review of a Delphi procedure and pilot studies by the LINNEAUS collaboration on patient safety in primary care. Eur J Gen Pract. 2015;21(Suppl9513566):50\u0026ndash;5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3109/13814788.2015.1043725\u003c/span\u003e\u003cspan address=\"10.3109/13814788.2015.1043725\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWeinhold I, Gurtner S. Understanding shortages of sufficient health care in rural areas. Health Policy. 2014;118(2):201\u0026ndash;14. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.healthpol.2014.07.018\u003c/span\u003e\u003cspan address=\"10.1016/j.healthpol.2014.07.018\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHall-Lipsy E, Anderson EJ, Taylor AM, Warholak T, Axon DR, Faqeeri Z, et al. Community health worker perspectives of an academic community medication therapy management collaboration. J Am Pharm Assoc. 2020;60(3):475\u0026ndash;80. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s13300-018-0373-9\u003c/span\u003e\u003cspan address=\"10.1007/s13300-018-0373-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePassey D, Healy R, Qualls J, Hamilton CJ, Tilley E, Burningham Z, et al. Development and implementation of a pharmacist-led telehealth medication management program for veterans receiving oral antineoplastic therapies through the MISSION Act. Am J Health Syst Pharm. 2022;79(11):835\u0026ndash;43. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1093/ajhp/zxac023\u003c/span\u003e\u003cspan address=\"10.1093/ajhp/zxac023\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLitke J, Spoutz L, Ahlstrom D, Perdew C, Llamas W, Erickson K. Impact of the clinical pharmacy specialist in telehealth primary care. Am J Health-Syst Pharm AJHP Off J Am Soc Health-Syst Pharm. 2018;75(13):982\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2146/ajhp170633\u003c/span\u003e\u003cspan address=\"10.2146/ajhp170633\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHogan KA, Lapenskie J, Leclair J, Thick N, Gazarin M, Webster P, et al. Implementing Safe Practices in Administering Pro re nata Medications in a Rural Hospital. J Patient Saf. 2019;15(4):302\u0026ndash;4. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/PTS.0000000000000276\u003c/span\u003e\u003cspan address=\"10.1097/PTS.0000000000000276\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTong EY, Hua PU, Edwards G, Van Dyk E, Yip G, Mitra B, et al. Partnered pharmacist medication charting (PPMC) in regional and rural general medical patients. Aust J Rural Health. 2022;30(5):593\u0026ndash;600. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/ajr.12895\u003c/span\u003e\u003cspan address=\"10.1111/ajr.12895\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGazarin M, Devin B, Tse D, Mulligan E, Naciuk M, Duncan S, et al. Evaluating an inpatient deprescribing initiative at a rural community hospital in Ontario. Can Pharm J. 2020;153(4):224\u0026ndash;31. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/1715163520929734\u003c/span\u003e\u003cspan address=\"10.1177/1715163520929734\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSova PM, Holmstr\u0026ouml;m AR, Airaksinen M, Sneck S. Using Healthcare Failure Mode and Effect Analysis in prospective medication safety risk management in secondary care inpatient wards. \u003cem\u003eEur J Hosp Pharm\u003c/em\u003e. 2022; Oct 5:ejhpharm-2021-003109. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/ejhpharm-2021-003109\u003c/span\u003e\u003cspan address=\"10.1136/ejhpharm-2021-003109\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhalil H, Lee S. The implementation of a successful medication safety program in a primary care. J Eval Clin Pract. 2018;24(2):403\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/jep.12870\u003c/span\u003e\u003cspan address=\"10.1111/jep.12870\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCelikkayalar E, Myllyntausta M, Grissinger M, Airaksinen M. Adapting and remodelling the US Institute for Safe Medication Practices\u0026rsquo; Medication Safety Self-Assessment tool for hospitals to be used to support national medication safety initiatives in Finland. Int J Pharm Pract. 2016;24(4):262\u0026ndash;70. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/ijpp.12238\u003c/span\u003e\u003cspan address=\"10.1111/ijpp.12238\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eInstitute for Safe Medication Practices. ISMP Medication Safety Self Assessment for Hospitals. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ismp.org/assessments/hospitals\u003c/span\u003e\u003cspan address=\"https://www.ismp.org/assessments/hospitals\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed on 21 May 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eInstitute for Safe Medication Practices Canada. Hospital Medication Safety Self-Assessment. 2016. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://mssa.ismp-canada.org/hospital\u003c/span\u003e\u003cspan address=\"https://mssa.ismp-canada.org/hospital\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 1 Jun 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKaufmann CP, St\u0026auml;mpfli D, Mory N, Hersberger KE, Lampert ML. Drug-Associated Risk Tool: Development and validation of a self-assessment questionnaire to screen for hospitalised patients at risk for drug-related problems. BMJ Open. 2018;8:e016610. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/bmjopen-2017-016610\u003c/span\u003e\u003cspan address=\"10.1136/bmjopen-2017-016610\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTupper J, Coburn A, Loux S, Moscovice I, Klingner J, Wakefield M. Strategies for Improving Patient Safety in Small Rural Hospitals. In: Henriksen K, Battles JB, Keyes MA, editors. Advances in Patient Safety: New Directions and Alternative Approaches (Vol 2: Culture and Redesign). Rockville (MD). Agency for Healthcare Research and Quality (US). 2008;Aug. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www-ncbi-nlm-nih-gov.libproxy.helsinki.fi/books/NBK43709/\u003c/span\u003e\u003cspan address=\"https://www-ncbi-nlm-nih-gov.libproxy.helsinki.fi/books/NBK43709/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed on 24 Aug 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePanesar SS, DeSilva D, Carson-Stevens A, Cresswell KM, Salvilla SA, Slight SP, et al. How safe is primary care? A systematic review. BMJ Qual Saf. 2016;25(7):544\u0026ndash;53. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/bmjqs\u003c/span\u003e\u003cspan address=\"10.1136/bmjqs\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSuvikas-Peltonen E, Granfors E, Celikkayalar E, Laaksonen R, Palmgren J, Airaksinen M. Development and content validation of an assessment tool for medicine compounding on hospital wards. Int J Clin Pharm. 2016;38:1457\u0026ndash;63. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s11096-016-0389-z\u003c/span\u003e\u003cspan address=\"10.1007/s11096-016-0389-z\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMinistry of Social Affairs and Health. Wellbeing services counties will be responsible for organising health, social and rescue services. 2023. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://stm.fi/en/wellbeing-services-counties\u003c/span\u003e\u003cspan address=\"https://stm.fi/en/wellbeing-services-counties\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed on 10 Nov 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKangas O, Kalliomaa-Puha L. Finland finalises its largest-ever social and healthcare reform, ESPN Flash Report 2022/39. European Social Policy Network (ESPN), Brussels: European Commission. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://ec.europa.eu/social/BlobServlet?docId=25947\u0026amp;langId=en\u003c/span\u003e\u003cspan address=\"https://ec.europa.eu/social/BlobServlet?docId=25947\u0026amp;langId=en\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed on 26 Aug 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eValvira. Under a new act, all social and health care service providers must be registered. 2023. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.valvira.fi/web/en/-/under-a-new-act-all-social-and-health-care-service-providers-must-be-registered\u003c/span\u003e\u003cspan address=\"https://www.valvira.fi/web/en/-/under-a-new-act-all-social-and-health-care-service-providers-must-be-registered\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed on 26 Aug 20023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNational institute for Health and Welfare. Statistical Yearbook on Social Welfare and Health Care. 2020. Vantaa: National Institute for Health and Welfare; 2021 p. 328. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://urn.fi/URN:ISBN:978-952-343-615-2\u003c/span\u003e\u003cspan address=\"https://urn.fi/URN:ISBN:978-952-343-615-2\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed on 5 Aug 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLapin liitto. Information about Lapland. 2017. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.lapinliitto.fi/en/information/general-information-about-lapland/\u003c/span\u003e\u003cspan address=\"https://www.lapinliitto.fi/en/information/general-information-about-lapland/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed on 21 May 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKarhinen E. Selvitys sairaansijojen m\u0026auml;\u0026auml;r\u0026auml;st\u0026auml; ja alueellisesta jakautumisesta Suomessa: Taustaselvitys rakennusinvestointien tarpeen arviointiin. Ministry of Social Affairs and Health Report 2020:36. Abstract available in English. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://urn.fi/URN:ISBN:978-952-00-8355-7\u003c/span\u003e\u003cspan address=\"http://urn.fi/URN:ISBN:978-952-00-8355-7\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed on 7 Sep 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHasson F, Keeney S, McKenna H. Research guidelines for the Delphi survey technique. J Adv Nurs. 2000;32(4):1008\u0026ndash;15. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1046/j.1365-2648.2000.t01-1-01567.x\u003c/span\u003e\u003cspan address=\"10.1046/j.1365-2648.2000.t01-1-01567.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOkoli C, Pawlowski SD. The Delphi method as a research tool: an example, design considerations and applications. Inf Manage. 2004;42(1):15\u0026ndash;29.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCampbell SM, Cantrill JA. Consensus methods in prescribing research. J Clin Pharm Ther. 2001;26(1):5\u0026ndash;14. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/J.1365-2710.2001.00331.X\u003c/span\u003e\u003cspan address=\"10.1111/J.1365-2710.2001.00331.X\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShang Z. Use of Delphi in health sciences research: A narrative review. Medicine. 2023;102(7):e32829. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/MD.0000000000032829\u003c/span\u003e\u003cspan address=\"10.1097/MD.0000000000032829\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOksa E, Olin K, Airaksinen M, Celikkayalar E. L\u0026auml;\u0026auml;kitysturvallisuuden itsearviointi sairaalassa - itsearviointity\u0026ouml;kalun p\u0026auml;ivitys. \u003cem\u003eDosis\u003c/em\u003e. 2021;37(1):16\u0026ndash;54. Abstract available in English. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://dosis.fi/wp-content/uploads/2021/03/016-055_Dosis_1-2021_Oksa_Olin.pdf\u003c/span\u003e\u003cspan address=\"https://dosis.fi/wp-content/uploads/2021/03/016-055_Dosis_1-2021_Oksa_Olin.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed on 21 May 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTeinil\u0026auml; T, Halmepuro-Jaatinen S, Yritys K, Manni K, Airaksinen M. Adapting the US Institute for Safe Medication Practices\u0026rsquo; Medication Safety Self Assessment tool for community pharmacies in Finland. Int J Pharm Pract. 2012;20(1):15\u0026ndash;24. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/j.2042-7174.2011.00158.x\u003c/span\u003e\u003cspan address=\"10.1111/j.2042-7174.2011.00158.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTaylor E. We Agree, Don\u0026rsquo;t We? The Delphi Method for Health Environments Research. Health Environ Res Des Journa. 2020;13(1):11\u0026ndash;23. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/1937586719887709\u003c/span\u003e\u003cspan address=\"10.1177/1937586719887709\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLaukkanen E, Ruokoniemi P, editors. Safe pharmacotherapy Guide to producing a pharmacotherapy plan. Helsinki: Ministry of Social Affairs and Health. Report 2021;6:1\u0026ndash;116. Abstract available in English. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://urn.fi/URN:ISBN:978-952-00-8682-4\u003c/span\u003e\u003cspan address=\"http://urn.fi/URN:ISBN:978-952-00-8682-4\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed on 2 Mar 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAgency for Healthcare Research. Hospital Survey on Patient Safety Culture Version 2.0. Agency for Healthcare Research. 2019. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/SOPS-Hospital-Survey-2.0-5-26-2021.pdf\u003c/span\u003e\u003cspan address=\"https://www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/SOPS-Hospital-Survey-2.0-5-26-2021.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed on 14 Feb 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSingla AK, Kitch BT, Weissman JS, Campbell EG. Assessing patient safety culture: A review and synthesis of the measurement tools. J Patient Saf. 2006;2(3):105\u0026ndash;15. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/01.jps.0000235388.39149.5a\u003c/span\u003e\u003cspan address=\"10.1097/01.jps.0000235388.39149.5a\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eClinical Excellence Commission. Medication Safety Self Assessment for Australian Hospitals. 2015. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.cec.health.nsw.gov.au/__data/assets/pdf_file/0011/326909/MSSA-Complete-Workbook-2015.pdf\u003c/span\u003e\u003cspan address=\"https://www.cec.health.nsw.gov.au/__data/assets/pdf_file/0011/326909/MSSA-Complete-Workbook-2015.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed on 6 Sep 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMurray M, Cope V, Leadership. Patient safety depends on it! Collegian. 2021;28(6):604\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.colegn.2021.07.004\u003c/span\u003e\u003cspan address=\"10.1016/j.colegn.2021.07.004\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eK\u0026uuml;nzle B, Kolbe M, Grote G. Ensuring patient safety through effective leadership behaviour: A literature review. Saf Sci. 2010;48(1):1\u0026ndash;17. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.ssci.2009.06.004\u003c/span\u003e\u003cspan address=\"10.1016/j.ssci.2009.06.004\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChambers B, Fleming C, Packer A, Botha L, Hawthorn G, Nott S. Virtual clinical pharmacy services: A model of care to improve medication safety in rural and remote Australian health services. Am J Health Syst Pharm. 2022;79(16):1376\u0026ndash;84. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/ajhp/zxac082\u003c/span\u003e\u003cspan address=\"10.1093/ajhp/zxac082\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMeyer-Massetti C, Cheng CM, Schwappach DLB, Paulsen L, Ide B, Meier CR, et al. Systematic review of medication safety assessment methods. Am J Health Syst Pharm. 2011;68(3):227\u0026ndash;40. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.2146/ajhp100019\u003c/span\u003e\u003cspan address=\"10.2146/ajhp100019\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFinnish Nationa Board on Research Integrity Tenk, Advice, Materials. 2024. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://tenk.fi/en/advice-and-materials\u003c/span\u003e\u003cspan address=\"https://tenk.fi/en/advice-and-materials\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed on 29 May 2024.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Supplementary File","content":"\u003cp\u003eAppendix 1 is not available with this version.\u003c/p\u003e\u003cp\u003eAppendix 1. Questionnaires Q1-Q4\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"medication safety, medication process, risk management, primary care, risk assessment, rural, self-assessment","lastPublishedDoi":"10.21203/rs.3.rs-4518075/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4518075/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eIn rural areas, primary care faces several challenges, and medication therapy is one of the most complex processes in primary care. With a specific, proactive, medication-safety self-assessment tool designed for rural primary care units, healthcare professionals could identify development needs in their medication processes.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThe Delphi consensus method with two Delphi rounds was used to create a medication-safety self-assessment tool for rural primary care units in Finnish Lapland. A preliminary tool was designed based on three national and international risk management tools. Statements of the preliminary tool were evaluated with a two-round Delphi panel by 12 experts in primary care and patient safety. Evaluated aspects were suitability for primary care settings, patient safety relevance, and necessity of the statements to be included in the developed rural, primary care, medication-safety self-assessment tool.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eIn the first Delphi round, a consensus was reached on 39% of the statements (n\u0026thinsp;=\u0026thinsp;118/304), of which 86% (n\u0026thinsp;=\u0026thinsp;101/118) were included, and 14% (n\u0026thinsp;=\u0026thinsp;17/118) were excluded from the final primary care medication- safety self-assessment tool. In the second round, 84% of the statements (n\u0026thinsp;=\u0026thinsp;141/167) reached a consensus, of which 70% (n\u0026thinsp;=\u0026thinsp;98/141) were excluded and 30% (n\u0026thinsp;=\u0026thinsp;43/141) included in the final tool. The included 144 statements were divided into 12 thematic sub-groups: 1. Patient information, 2. Drug information, 3. Communication of drug orders and other drug information; 4. Drug labeling, packaging and nomenclature; 5. Drug storage and distribution, 6. Medication device acquisition and use, 7. Environmental factors, workflow and staffing patterns; 8. Staff competency and education, 9. Patient education, 10. Preventive risk management, 11. Learning from medication safety incidents, and 12. Electronic health record.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe developed medication-safety self-assessment tool is targeted for proactive medication risk management in rural primary care settings. While experts reached a consensus for the PMSSA tool contents, adoption of the tool to suit the rural primary care environments in different countries should be further investigated.\u003c/p\u003e","manuscriptTitle":"Developing a medication-safety self-assessment tool for rural primary care units - A case from Finnish Lapland","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-20 15:12:32","doi":"10.21203/rs.3.rs-4518075/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-06-06T05:54:43+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-06-04T00:42:35+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-06-04T00:42:35+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Primary Care","date":"2024-06-02T18:41:33+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"daddff6b-66f2-4088-950c-6a83c21b0dd3","owner":[],"postedDate":"June 20th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-02-10T16:05:10+00:00","versionOfRecord":{"articleIdentity":"rs-4518075","link":"https://doi.org/10.1186/s12875-025-02722-3","journal":{"identity":"bmc-primary-care","isVorOnly":false,"title":"BMC Primary Care"},"publishedOn":"2025-02-07 15:58:10","publishedOnDateReadable":"February 7th, 2025"},"versionCreatedAt":"2024-06-20 15:12:32","video":"","vorDoi":"10.1186/s12875-025-02722-3","vorDoiUrl":"https://doi.org/10.1186/s12875-025-02722-3","workflowStages":[]},"version":"v1","identity":"rs-4518075","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4518075","identity":"rs-4518075","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}