pharmacist attitude

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Original Research

Understanding the attitudes of hospital pharmacists

to reporting medication incidents: A qualitative study

Steven D. Williams, M.Phil.a,b,*, DenhamL.Phipps, Ph.D.b,Darren M. Ashcroft, Ph.D.a,b

aDepartment of Pharmacy, University Hospital of South Manchester NHS Foundation Trust, Southmoor Road,

Wythenshawe, Manchester M23 9LT, UKbCentre for Pharmacoepidemiology and Drug Safety Research, School of Pharmacy and Pharmaceutical Sciences,

Manchester Academic Health Sciences Centre (MASHC), University of Manchester, Manchester, UK

Abstract

Background: The attitudes of doctors, nurses, and midwives to reporting errors in health care have been

extensively studied, but there is very limited literature considering pharmacists attitudes to medication

error reporting schemes, in particular in hospitals.

Objectives: To explore and understand the attitudes of hospital pharmacists to reporting medication

incidents.

Methods:Focus groups were conducted with a total of 17 hospital pharmacists from 4 purposively sampled

hospitals in the North West of England. The recordings of the focus groups were transcribed verbatim and

subject to thematic analysis using a framework analysis approach.

Results:Pharmacists agreed that the high prevalence of medication errors, especially prescribing errors of

omission, has led to an acceptance of not using hospital reporting systems. There were different personal

thresholds for reporting medication errors but pharmacists agreed that the severity of any patient harm

was the primary reporting driver. Hospital pharmacists had specific anxieties about the effects of reporting

on interprofessional working relationships with doctors and nurses, but felt more confident to report if they

had previously witnessed positive feedback and system change following an error. Existing reporting forms

were considered too cumbersome and time consuming to complete, as pharmacists felt the need to find and

record every possible detail.

Conclusions: Hospital pharmacists understood the importance of reporting medication incidents, but

because of the high number of errors they encounter do not report them as often as may be expected. Thedecision to report was a complex process that depended on the severity of patient harm, anxieties about

harming interprofessional relationships, prior experience of the outcomes from reporting, and the perceived

effort required to use reporting forms.

2013 Elsevier Inc. All rights reserved.

Keywords: Medication incidents; Hospital pharmacists; Error reporting; Adverse events; Patient safety

* Corresponding author. Department of Pharmacy, University Hospital of South Manchester NHS Foundation

Trust, Southmoor Road, Wythenshawe, Manchester M23 9LT, UK. Tel.:44 (0)161 291 2113.E-mail address: [email protected](S.D. Williams).

1551-7411/$ - see front matter 2013 Elsevier Inc. All rights reserved.

doi:10.1016/j.sapharm.2012.02.002

Research in Social and

Administrative Pharmacy 9 (2013) 8089
mailto:[email protected]://dx.doi.org/10.1016/j.sapharm.2012.02.002http://dx.doi.org/10.1016/j.sapharm.2012.02.002mailto:[email protected]


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Introduction

The interest in health care adverse events

(errors/incidents) has increased substantially fol-

lowing the publication of the Institute of Medi-

cines (IOM) To err is human report in theUnited States,1 an Organization with a Memory

in the UK,2 and similar reports in other developed

countries.3,4 Although the scale of the problem

appears large, with the IOM reporting that more

than 1 million preventable adverse events occur

each year in the United States, the reality is that

the problem is probably even larger, with esti-

mates of under reporting of events ranging from

50% to 96% annually.5

The attitudes of doctors, nurses, and midwives

to reporting errors in health care have been exten-

sively studied in general medical/surgicalcare6,7 andacross a wide range of specialties including obstet-

rics,8 paediatrics,9 intensive care,10 and in the

nursing home setting.11 With the possible exception

of obstetricians and midwives,12,13 the attitudes of

health professionals to reporting errors appear to

be driven by negative attitudes about why not

report (barriers), as opposed to positive attitudes

about why they should report (benefits). The

barriers have consistently been found to be broadly

4-fold: knowledge of what and when to report, the

effort required to complete a report, the personalfears about the consequences of reporting, and

the perceived lack of feedback or positive change

following an error report.14

There is very limited literature considering

pharmacists attitudes. Clearly, the training, role,

and function of hospital pharmacists in the medi-

cine use process are very different to medical and

nursing colleagues, which may mean that their atti-

tudes to errors and reporting behavior is different.

From the published literature, it would appear

that apprehension and suspicion about reporting

schemes because of the fears of the consequencesfor the pharmacist involved in the error, appear

to be the overriding attitude of pharmacists to

reporting medication errors.15-17

Semistructured interviews with 36 pharmacy

staff from a U.S. teaching hospital revealed that

pharmacy staff made a conscious decision whether

to formally report an incident via the hospital report-

ing system or document the incident as a pharmacy

intervention, as it affected their annual appraisal.15

Staff were formally rewarded at appraisal for inter-

ventions made, but formally recorded incidents in-volving themselves were used to compare staff with

their peers. Thedepartment promoted a nonpunitive

culture but staff perception of that varied and phar-

macists rarely filed formal incident forms involving

themselves or other pharmacy colleagues.

A U.S. focus group study considered barriers to

reporting as part of a broader evaluation of a re-

gional medication error reporting system, where the14 health professionals were involved in either data

collection or utilization.16 Inadequate staffing was

identified as a major barrier to reporting because

of the time-consuming nature of confirming medi-

cation errors and the collection of relevant details.

Suggestions for improving reporting rates included

dedicated medication safety managers or increasing

the use of pharmacy technical support staff.

A questionnaire study investigating the likeli-

hood of reporting adverse events with 275 UK

community pharmacy staff revealed a lack ofunderstanding about reporting schemes and a

deep resentment and mistrust about their need,

due to fears of repercussions for the pharmacist

involved.17 Nine different scenarios involving dis-

pensing or supply of a medicine, and whether the

behavior of the community pharmacist involved

compliance (in line with protocol), violation (de-

liberate deviation from protocol), or error (not

being aware of a protocol) were presented but

participants were found to be unlikely or very un-

likely to report any of the events to a local, or the

national, reporting scheme.More recently, Boyle at al18 considered the atti-

tudes to medication incident reporting in a Web-

based survey involving 72 community pharmacy

staff in Canada. Pharmacists, pharmacy managers,

and pharmacy technicians were somewhat ambiva-

lent about the impact on day-to-day operations, the

ease of completion of current reporting systems,

and the personal support given to individuals in-

volved in errors. The 2 most common complaints

about reporting systems were the lack of a formal

process and feedback after an error had occurred.The ability of a system to encourage more open

learning and ultimately reduce medication inci-

dents, in addition to the need for appropriate train-

ing and technical support for the system, were

identified as some of the most desirable features of

any new incident reporting system. Similarly, the

sharing of learning from errors, and ensuring ano-

nymity for staff, were rated most highly as factors

that would likely increase reporting and learning.

The attitudes of UK hospital pharmacists

to reporting medication errors are currently un-

known,yet in therecentEQUIP study theprevalenceof prescribing errors alone in UK hospitals was

81Williams et al. / Research in Social and Administrative Pharmacy 9 (2013) 8089


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found to be almost 9%.19 The observed difference

between the detection and reporting of medication

errors in the 19 hospitals studied was stark with

less than 0.2% of the detected prescribing errors be-

ing voluntarily reported via the hospitals incident

reporting system (P. Lewis, EQUIP researcher, per-sonal communication, 10th August 2011). Similarly,

a direct observation of medication administration in

36 U.S. hospitals revealed an 11.7% error rate com-

pared with just 0.04% for errors detected through the

incident reporting scheme.20

If the benefit of reporting errors is for organi-

zations to learn, and change practices/systems to

improve medication safety, then the literature

suggests that individual hospitals do not have all

the necessary medication incident data to accom-

plish this. This may therefore be inhibiting theability of hospitals to learn from medication errors

and more importantly to take steps to protect

future patients from repetitive medication harms.

A better understanding of why hospital pharma-

cists do not appear to report medication errors that

occur is therefore warranted, particularly as there is

also emerging evidence that better voluntary in-

cident reporting per se is associated with a more

positive patient safety culture in hospitals.21

MethodsEthical approval for this study was granted

from the South Manchester NHS Research Ethics

Committee to invite hospital pharmacists from

4 hospitals, in the North West of England, to take

part in the study.

Purposive sampling was used to invite different

sized and types of hospitals, whose pharmacy staff

had scored them positively, neutrally, and nega-

tively in a previous survey exploring the attitudes

of pharmacy staff to patient safety climate.22

Lead clinical pharmacy managers in the 4 hos-pitals were asked to invite, by e-mail, all pharma-

cists in their department with the aim of recruiting

1 pharmacist from each pay band (representing

seniority and experience), up to a maximum of

7 pharmacists.

An interview schedule was designed to help

establish local hospital reporting and learning

systems, and participants positive and negative at-

titudes to reporting medication errors. The schedule

was based on the extensive literature studyingtheat-

titudes and barriers to reporting incidents6,7,23

(Appendix).The focus groups were conducted between May

and June 2008 and typically lasted between 40 and

60 minutes. The digital recordings of the focus

groups were transcribed verbatim and then read in

detail by the researchers on multiple occasions.

The data were subject to thematic analysis by the

lead researcher (SDW) using a framework analysis

approach.24 Framework analysis allows some ini-tial assumptions based on the literature to be

used but is a systematic process using 5 key stages

to analyze and sort data according to emergent key

themes: familiarization, identifying a thematic

framework, indexing, charting, mapping, and in-

terpretation. The other members of the research

team (DMA, DP) additionally analyzed the data

independently to elucidate the final emergent

themes from the focus groups.

Results

The characteristics of the pharmacists recruited

from the 4 hospitals who took part in the focus

groups are shown inTable 1. The size of the focus

groups varied between 2 and 6 pharmacists, and

the overall gender mix was 12 females to 5 males,

which is inline with UK-hospital pharmacy work-

force data.25

Three out of the 4 hospitals used paper in-

cident reporting forms and 1 had a fully electronic

incident reporting system. The 3 hospitals with

paper forms had 2 different types of error report-ing forms, 1 which was hospital wide for reporting

any type of incident, including medication errors,

and another internal form that was exclusively for

pharmacy staff to report either dispensing errors

or other medication errors only.

In general terms, pharmacists from 2 of the

pharmacy departments appeared very comfortable

reporting medication errors and were very positive

about the benefits of reporting, because of a per-

ception of strong pharmacy leadership and a his-

tory of constructive changes following reportedmedication errors. One of those hospitals had

a medication safety pharmacist whose role was to

escalate the internal pharmacy reporting forms,

via the hospital wide system, on behalf of the re-

porting pharmacist when the incident appeared

to be a serious or a repetitive system type error.

The remaining pharmacy departments appeared

to have an overriding anxiety about the effect of

reporting on their professional relationships with

other health professionals, and 1 appeared to be

adversely affected by a recent internal investigation

regarding a medication error. Framework analysisof the 4 focus groups revealed 7 main themes, with

associated subthemes as presented inTable 2.

82 Williams et al. / Research in Social and Administrative Pharmacy 9 (2013) 8089


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Working environment

An important theme that emerged was the

NHS hospital environment in which pharmacists

operate, where medication errors are considered

to be endemic and was accepted as part of the

job to identify and report medication errors.

However, given that workload pressures were so

intense all participants felt that medication errors

do not get reported as often as they should, even if

they wanted to report them all.

If we reported every time something was missed off

a patients drug history wed probably make a re-

port about every patient.well, youd have no

time to do anything else. (Focus group 4: large

teaching hospital with electronic reporting

systemdFemale with 1 years pharmacy

experience.)

It was conceded that being busy was not

a good enough excuse not to report errors, but

that there was maybe a general apathy to report-

ing among pharmacists because of the scale of the

problem. The concept of a blame culture appeared

to exist with additional concerns about the way

different health professionals were treated follow-

ing an incident.

People still think, its a form, my God, someones

gonna come down from up on high and shoot me.

(Focus group 2: large teaching hospital with pa-

per reporting systemdMale with 4 years phar-

macy experience.)

.think there is certainly a perception and proba-

bly not an unwarranted one, that the way medical

staff are dealt with, treated, approached, when it

comes to when an error has happened is a lot differ-

ent. (Focus group 3: large general hospital with

paper reporting systemdMale with 4 years phar-

macy experience.)

Pharmacists appeared to feel more comfortable

reporting where there was a history of departmen-

tal and/or hospital belief in the benefits of reporting

but did not appear to welcome managerial requests

to just report more to justify hospital pharmacists

worth. There was also a belief that speaking di-

rectly to the health professionals involved in any er-

rors could be more successful, and less stressful,

than formally reporting the incident or writing in

clinical notes.

There are better ways of dealing with things that

still achieve the same end. Like yesterday. they

couldve filled an incident form in about that, but

instead of which weve dealt with it, weve sorted

it, the consultant is informed, the policys going

to be reviewed, the patients, you know, had the

treatment that they need, even though its not in

the guidelines, and. theres none of the witch-

hunt, kind of nobodys cross or upset about it and

everybodys like Oh, thanks a lot, were gonna

sort this out now. And that means that the problem

is resolved but we didnt fill an incident form in

even though we couldve. (Focus group 1: small

general hospital with paper reporting systemd

Female with 18 years pharmacy experience.)

Table 1

Characteristics of the focus groups

Focus group 1 Focus group 2 Focus group 3 Focus group 4

Type of hospital General University teaching General University teaching

Number of acute beds 350 900 750 1100

Gender of

participants

5 female 4 female 1 female 2 female

2 male 3 male

Hospital pharmacy

experience

of participants

F1 23 yr F1 4 yr F1 6 yr F1 1 yr

F2 18 yr F2 5 yr M1 4 yr F2 2 yr

F3 3 yr F3 3 yr M2 11 yr

F4 1 yr F4 6 yr M3 22 yr

F5 13 yr M1 4 yr

M2 20 yr

Medication error

reporting system

in place at study

hospitals

Paper hospital wide

incident form plus

pharmacy-specific

dispensing error

form if errordetected before

leaving department

Paper hospital wide

incident form plus

pharmacy-specific

form for recording

medication errorsidentified in

pediatrics only

Paper incident form

specifically for

medication errors

(escalated to

hospital wideincident form by

dedicated

pharmacist as

necessary)

Electronic hospital

wide incident

form



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Anxieties

The vast majority of hospital pharmacists

worried about the effects of reporting medication

errors on interprofessional working relationships

with doctors and nurses.

Its just that when you go and say, Im gonna be

filling in an incident form about such and such.

Theres kind of a look as if to say, Youre

a traitor.. Youre meant to be on our side, you

work on our ward.(Focus group 2: large teaching

hospital with paper reporting systemdMale with

4 years pharmacy experience.)

Unless, the pharmacist was comfortable that

the team they worked within was prepared for,and wanted them, to report the medication errors

there was real hesitancy about reporting.

If youre working in a fairly discrete clinical team,

pharmacists have, I think, historically had difficulty

finding a role within a team, finding acceptance of

people accepting pharmacists roles, and I think

sometimes you may be a little cautious about want-

ing to jeopardize that, particularly if its a teamthat you work closely with. (Focus group 3: large


Male with 4 years pharmacy experience.)

There was alsoagreementamong all participants

that junior pharmacists would have the greatest

concerns reporting more senior health professionals

involved in medication errors. Pharmacists clearly

understood the tensions that could be created by

medication error reports and often they had adop-

ted strategies to try to reduce this conflict, such as

educating prescribers about their actions.

If youve got a new house officer, and they make

a mistake and its because of their inexperience,

youre probably more likely to sit down and say,

Youve put this medication on the wrong person,

what can we do about it? And then if they do it

again you fill out an incident report, but possibly

on the first one youre less likely to because youre

building a professional relationship and also you

have an inexperienced colleague who you can edu-

cate.(Focus group 2: large teaching hospital with

paper reporting systemdFemale with 6 years

pharmacy experience.)

However, the alternative was for pharmacists

to choose not to report medication errors because

of their anxieties, especially when senior medical

and nursing staff had openly tried to discourage

pharmacists from reporting.

I made. an unfortunate error of suggesting to a se-

nior doctor that he fill out an incident report on

something that had happened on a ward and had

my head bitten off.(Focus group 2: large teaching

hospital with paper reporting systemdFemale

with 6 years pharmacy experience.)

Personal fears about reporting medication errors

were raised by pharmacists in only 1 focus group

and the feeling was that internal investigations,

although valid, needed to be performed more

sensitively.

The incident

The nature of the medication errors themselves

was the most frequently identified issue that influ-

enced pharmacists decisions to report a medication

incident or not. The vast majority of participants

were in no doubt that theactual severity of a medica-tion error overrode everything else when consider-

ing reporting, and that hospital pharmacists first

Table 2

Thematic framework

Theme Subtheme

Environment Management

Job role

Blame culture

Interprofessional differences

Workload pressures

Direct communication

Anxieties Personal

Professional relationships

Seniority

Incident Severity

Drug

System error

Justification

Repetition

Personal judgmentOmission errors (medicines

reconciliation)

System Time

Data set

Paper vs electronic

Anonymity

Form confusion

Learning Change in practice

In action

Improve safety/care

Reporter confidence

Positive feedback

Preventing recurrenceIdentify safety problem

Improvements Form simplicity

Targeted reporting

Anonymity

Technology

Feedback

Drug specific



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think whether the patient came to any serious harm

before considering whether to report.

I mean I always think of things in terms of could it

prolong their stay in hospital or could

It.similar to, I suppose, the adverse drug reac-

tions really, where, you know, if it resulted in or

prolonged hospital admission or caused them

some damage of some description. (Focus group

1: small general hospital with paper reporting

systemdFemale with 18 years pharmacy

experience.)

Incidents with only a potential for patient

harm (including prescribing omission errors on

admission to hospital detected through medicines

reconciliation) were generally accepted as being as

important in theory, but just occurring too

frequently to be reported with any regularity.[Because] if we reported every time something was

missed off a patients drug history wed probably

make a report about every patient. (Focus group

4: large teaching hospital with electronic report-

ing systemdFemale with 2 years pharmacy

experience.)

The injustice to both patients and health pro-

fessionals and the failure to possibly identify

patterns of error by not reporting no harm errors

were however accepted as negative consequences

to this approach.A number of other subthemes emerged that

indirectly linked the severity of the incident with

the consideration to report, namely the drug itself,

repetition of the error, and system or personal

negligence type errors.

But methotrexate 2.5 and methotrexate 10 is ex-

actly the same relationship as atenolol 25 and ate-

nolol 100 but the results of muddling them up

arent the same, but its the same error, so really

you should be reporting them as an error type.

Thats what I always feel.I wouldnt report the

atenolol, but really you should because its exactlythe same thing, isnt it. (Focus group 1: small gen-

eral hospital with paper reporting systemd

Female with 13 years pharmacy experience.)

I dont know how I would define significant, but

something that Id maybe seen a trend of, that

might make me start thinking, This is a trend

Im seeing, unless I start reporting this nobody

else is going to see this. (Focus group 3: large gen-

eral hospital with paper reporting systemdMale

with 4 years pharmacy experience.)

If you know a doctor who, on a regular occasion,

makes the same error and if you dont fill out an in-

cident form theyre never gonna get pulled up,

whereas if you do fill an incident form then they

might. (Focus group 2: large teaching hospital

with paper reporting systemdFemale with 6 years


Several participants highlighted a practice of

sometimes reporting an incident to justify them-

selves and being more likely to report the same

type of error made by pharmacists in the dispen-

sary, rather than by doctors on ward. These both

appear to refer back to the subthemes of a blame

culture in some hospital working environments

and anxieties about reporting other health

professionals.

It was clear from all focus group participants

that each pharmacist held different thresholds for

reporting medication errors dependent on a par-

ticular set of circumstances affected by the sub-

themes identified above.

The classic is everybodys got different thresholds

for reporting different things. It probably varies

on the day of the week and it varies on your

mood.and it may be less on a Sunday than on

a Monday. (Focus group 2: large teaching hospi-

tal with paper reporting systemdMale with


The reporting system

Incident reporting forms not exclusively de-

signed for medication error reporting, paper or

electronic, were felt by all to be cumbersome andhad too many unnecessary fields that had to be

completed.

Balance between what data set is workable, be-

cause pharmacists being pharmacists, give us

a form, theres 60 boxes on it, well attempt to

fill 60 boxes because thats what we do. (Focus

group 2: large teaching hospital with paper re-

porting systemdMale with 20 years pharmacy

experience.)

This appeared to mean that pharmacists either;

did not complete the forms because of the amount

of time needed; or because of anxieties about

professional relationships they go to great lengths

to complete the form to make sure they do not

implicate a health professional incorrectly.

Not knowing the full detail of exactly the entire in-

cident. Because you think, Im gonna have to go

back and look through all the notes, blah-blah-

blah, and again its probably a time thing but if

you dont know, you dont wanna lay the blame

at somebody. (Focus group 2: large teaching hos-

pital with paper reporting systemdFemale with 3

years pharmacy experience.)

The presence of more than 1 incident form

appeared to cause misunderstanding and confusion



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about which types of errors should be reported, and

on what forms. There was disagreement about the

importance of anonymous reporting, with junior

pharmacists confident that health professionals

would know anyway if their ward pharmacist had

reported them. Participants who had been exposedto an electronic reporting system disagreed whether

it would be easier than a paper system.

Learning

There was universal agreement between partic-

ipants about the perceived benefits of reporting to

improve medication safety by identifying persistent

problems, to which solutions could then be found.

Obviously its really important that this doesnt

happen again and if you didnt know then that

means lots of other people didnt know about this

and so I have to fill this form in to make sure

that this gets identified by the Trust, so that it

doesnt happen and other people get warned about

this. (Focus group 1: small general hospital with

paper reporting systemdFemale with 18 years


There was however a clear split between the

focus groups and their experiences of positive

feedback and change following reported errors.

Two of the focus groups described their frustra-

tion at not receiving formal feedback about errorsreported, and even struggled to detail any changes

that had occurred as a result of the error

reporting.

I dont know how it works afterward. I dont know,

how much does a team come and look at the notes

and look at the patient cardex for them? I dont

know how its followed up really. I know theyre

e-mailed out to loads of people, Im not sure

what the follow up procedure is.you never get

feedback on ones youve reported yourself. (Focus

group 4: large teaching hospital with electronic

reporting systemd

Female with 1 years phar-macy experience.)

By contrast, 2 focus groups were pleased with

the positive changes that had been made as a result

of error reporting, even resulting in the funding of

an additional pharmacist post.

I think weve done a good job in explaining the ben-

efits of why were doing it, its not just to come and

hit you with a big stick, you know, and tell you

what youre doing wrong. (Focus group 3: large



Confidence in reporting medication errors was

unmistakable in those pharmacists who worked,

or had worked, in a hospital pharmacy depart-

ment demonstrating the positive benefits of re-

porting and supporting their pharmacists to feel

comfortable to do so.

Reflective learning.encourages you to find the rea-

sons why. It doesnt have, because youre an idiot.

on the list of reasons why the mistake was made, its

Was it busy? What else was going on? What

pressures were on you? And you start looking at

the way you work. (Focus group 3: large general



Weve got a massive, or weve got a major pedigree

of changing things in terms of prescribing as a result

of people flagging issues up, and the issues could be

flagged up in a multitude of ways, but a clinical inci-

dent form might be one of the ways that are used to

kind of like flag that up. (Focus group 2: largeteaching hospital with paper reporting systemd


Improvements in reporting

The need forpharmacists to notfeel chastised by

reporting and to receive positive feedback about

errors, and any changes subsequently imple-

mented, were regarded unanimously as the primary

drivers to improve medication error reporting.

Knowing that what youre doing is actually being seen,

read, heard by someone, and something is actually be-ing done about it.And trying to get rid, trying topro-

mote the open and learning, you know, so that people

dont have this antiquated idea that were actually out

to get them, that were actually trying to do it for the

benefit of not only the patient but their ward at the

same, or their area at the same time. (Focus group

2: large teaching hospital with paper reporting

systemdMale with 4 years pharmacy experience.)

Some pharmacists thought that the simple

issuing of letters to reporters after an incident

might help to improve reporting if they were more

positive than Thank you very much we havereceived your form. Given the prevalence of

medication errors in hospital proposals for im-

proving reporting were centered around a simpler

reporting system and reliance on targeted report-

ing by pharmacists.

People can become a bit snow-blind to kind of mul-

tiple reports of lots of things going on without any

clear focus about what youre trying to do to im-

prove it. So targeting certain sub-sections of a trust

for monitoring a specific target is one area, but

then deciding what you are gonna report and not

gonna report is key.(Focus group 3: large general





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Drug-specific error reporting forms with the

simplest of data sets were considered the best

practical way to improve reporting, with ideas

including the use of other staff to fully report

errors once the front line pharmacist had collected

the basic information. There was general supportthat electronic forms/systems would be easier than

paper ones but divided opinion as to the added

benefit of anonymous reporting.

Discussion

This studys aim was to establish the attitudes of

hospital pharmacists toward reporting medication

errors. The pharmacists understood that it was

part of their job to improve medication safety forpatients through reporting errors. However, due

to the endemic nature of medication errors, and

busy hospital working environments, pharmacists

do not report medication errors as often as they

would wish. This is a very important barrier to re-

porting medication errors that appears unique to

hospital pharmacists and participants agreed that

the prevalence of medication errors has probably

led to reporter apathy, which in turn has led to an

acceptance of not reporting.

The culture of blame, highlightedin the past 10

years of patient safety research,6,26 is recognizedby pharmacists in UK hospitals, but in contrast

to literature regarding UK community pharma-

cists17 and U.S. hospital pharmacists15, medical27

and nursing staff28 personal fears about litigation

and disciplinary procedures because of reporting

errors were not identified as a key concern.

For many years, hospital pharmacists have

strived to be accepted as equal partners in multi-

disciplinary clinical teams29,30 and to not be seen as

policemen31, and this study found that they often

hold specific anxieties about reporting medical andnursing staff because of those close working rela-

tionships. Hospital pharmacists, however, appear

to have adopted strategies to reduce such tensions

by either educating doctors at the time of an error,

or just not reporting the incident at all.

It is clear that, once happy to report, hospital

pharmacists were similar to their medical and

nursing colleagues28,32,33 in that the severity of

any patient harm was undoubtedly the primary

reporting driver. Pharmacists appeared to have

different personal thresholds for reporting medi-

cation errors, but there was universal agreementthat common prescribing errors of omission, dis-

covered as part of the medicines reconciliation

process were unlikely to be reported unless serious

harm had or was likely to have occurred.

Reporting forms, unless designed specifically

for medication errors were considered too cum-

bersome and time consuming to complete. The

detail conscious nature of pharmacists adds totheir anxieties about interprofessional relation-

ships as they feel that they have to find and record

every possible detail to ensure they do not in-

criminate a health professional unnecessarily. This

concurs with the work of Coley et al,16 where the

time-consuming nature of confirming and collect-

ing medication error details was identified as a ma-

jor barrier to reporting. This may be 1 plausible

hypothesis for why pharmacists do not complete

error reporting forms.

The differences between the focus groupsshowed clear evidence that positive feedback about

errors and witnessing positive changes to systems

following errors, rather than poor feedback and in

action, may encourage pharmacists to feel more

confident about reporting. This supports the find-

ings of Boyle et al18 in community pharmacies, and

an improved hospital safety culture has been asso-

ciated with less negative about barriers to report-

ing, leading to increased reporting.21,28,34

Participants in the focus groups were not ran-

domly selectedbutselfselected, after invitation from

their departmental clinical pharmacy manager. It ispossible that the sample may have only included

pharmacistsprepared to givean opinion on the topic

that was in part about not following hospital

guidance, when senior departmental colleagues

may have also been present. The focus group

facilitator was aware of these possible concerns

and tried to keep pharmacists at ease when poten-

tially difficult scenarios about errors were described.

The total number of pharmacists participating in the

focus groups was relatively small but with pharma-

cists with a wide range of experience from differentsized and type of hospital with different safety

cultures, it was sufficient to ensure data saturation

and to identify key attitudes to reporting.

A large quantitative survey of hospital phar-

macists is warranted to further explore and

quantify the attitudes to reporting mediation

errors identified in this qualitative study.

Conclusion

Hospital pharmacists understand the impor-

tance of reporting medication incidents to im-prove patient safety, but due in part to the

number of errors they encounter, they do not



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report them as often as they should. They appear

to have real anxieties that reporting will adversely

affect their working relationships with medical

and nursing staff but are more confident to report

if they have seen positive changes following

a reported incident. The decision to report anerror is a complex process for hospital pharma-

cists that depend primarily on the severity of any

patient harm, but it is unlikely for simple pre-

scribing errors of omission, identified as part of

medicines reconciliation on admission. The effort

required to use reporting forms is compounded

by pharmacists detail conscious nature fueling

a desire to record every possible detail.

References

1. Kohn LT, Corrigan JM, Donaldson MS.To Err is

Human. Washington, DC: National Academy Press;

1999.

2. Department of Health.An Organisation with a Mem-

ory, a Report from an Expert Working Group on

Learning from Adverse Events in the NHS. London,

UK: Department of Health; 2000.

3. National Steering Committee on Patient Safety.

Building a Safer System-a National Integrated Strat-

egy for Improving Patient Safety in Canadian Health

Care. Ottawa, ON: National Steering Committee

on Patient Safety; 2002.

4. Australian Council for safety and Quality in Health

Care. Safety First. Report to the Australian Health

Ministers Conference 27 July 2000. Canberra,

Australia: Australian Council for Safety and Quality

in Health Care; 2002.

5. Barach P, Small SD. Reporting and preventing med-

ical mishaps: lessons from non-medical near miss

reporting systems.BMJ2000;320:759763.

6. Sharma A, Jain P, Parmar B, Muzaffar J,

Monson JRT. Incident reporting in surgical

traineesdrevisited.J Patient Saf2008;4:191194.

7. Evans SM, Berry JG, Smith BJ, et al. Attitudes and

barriers to incident reporting: a collaborative hospi-tal study.Qual Saf Health Care 2006;15:3943.

8. Oconnor AM. The attitude of staff towards clinical

risk management.Clin Risk 1996;2:119122.

9. Taylor JA, Brownstein D, Christakis DA, et al. Use

of incident reports by physicians and nurses to docu-

ment medical errors in pediatric patients.Pediatrics

2004;114:729735.

10. Sanghera IS, Franklin BD, Dhillon S. The attitudes

and beliefs of healthcare professionals on the causes

and reporting of medication errors in a UK Intensive

care unit.Anaesthesia2007;62:5361.

11. Handler SM, Perera S, Olshansky EF, et al. Identify-

ing modifiable barriers to medication error reportingin the nursing home setting. J Am Med Dir Assoc

2007;8:568574.

12. Waring JJ. A qualitative study of the intra-hospital

variations in incident reporting. Int J Qual Health

Care2004;16:347352.

13. Vincent C, Stanhope N, Crowley-Murphy M. Rea-

sons for not reporting adverse incidents: an empirical

study. J Eval Clin Pract 1999;5:1321.14. Wakefield DS, Wakefield BJ, Uden-Holman T,

Borders T, Blegen M, Vaughn T. Understanding

why medication administration errors may not be re-

ported. Am J Med Qual1999;14:8188.

15. Tamuz M, Thomas EJ, Franchois KE. Defining and

classifying medical error: lessons for patient safety

reporting systems. Qual Saf Health Care 2004;13:

1320.

16. Coley KC, Pringle JL, Weber RJ, Rice K,

Ramanujam R, Sirio CA. Perceived barriers in using

a region-wide medication error reporting system.

J Patient Saf2006;2:3944.

17. Ashcroft DM, Morecroft C, Parker D, Noyce PR.Likelihood of reporting adverse events in community

pharmacy: an experimental study. Qual Saf Health

Care2006;15:4852.

18. Boyle TA, Mahaffey T, MacKinnon NJ, Deal H,

Hallstrom LK, Morgan H. Determinants of medica-

tion incident reporting, recovery, and learning in

community pharmacies: a conceptual model. Res

Soc Adm Pharm2011;7:93107.

19. Dornan T, Ashcroft D, Heathfield H, et al. An in

depth investigation into causes of prescribing errors

by foundation trainees in relation to their medical ed-

ucation. EQUIP study 2009. Available at: http://

www.gmc-uk.org/FINAL_Report_prevalence_and_

causes_of_prescribing_errors.pdf_28935150.pdf. Acce-

ssed 10.08.11.

20. Flynn EAB. Comparison of methods for detecting

medication errors in 36 hospitals and skilled-

nursing facilities.Am J Health Syst Pharm 2002;59:

436446.

21. Hutchinson A, Young TA, Cooper KL, et al.

Trends in healthcare incident reporting and rela-

tionship to safety and quality data in acute hos-

pitals: results from the National Reporting and

Learning System. Qual Saf Health Care 2009;

18:510.22. Williams SD, Ashcroft DM. Examining patient

safety climate in the hospital pharmacy setting:

a cross sectional survey. Int J Pharm Pract 2008;

16(suppl 3):C43C44.

23. Kingston MJ, Evans SM, Smith BJ, Berry JG. Atti-

tudes of doctors and nurses towards incident report-

ing: a qualitative analysis. Med J Aust 2004;181:

3639.

24. Ritchie J, Spencer L. Qualitative data analysis of re-

plied policy research. In: Bryman A, Burgess RG,

eds. Analysing Qualitative Data. London and New

York: Routledge; 1994. p. 173194.

25. Seston L, Hassell K.Pharmacy Workforce Census.London, UK: Royal Pharmaceutical Society of

Great Britain; 2009.

http://www.gmc-uk.org/FINAL_Report_prevalence_and_causes_of_prescribing_errors.pdf_28935150.pdfhttp://www.gmc-uk.org/FINAL_Report_prevalence_and_causes_of_prescribing_errors.pdf_28935150.pdfhttp://www.gmc-uk.org/FINAL_Report_prevalence_and_causes_of_prescribing_errors.pdf_28935150.pdfhttp://www.gmc-uk.org/FINAL_Report_prevalence_and_causes_of_prescribing_errors.pdf_28935150.pdfhttp://www.gmc-uk.org/FINAL_Report_prevalence_and_causes_of_prescribing_errors.pdf_28935150.pdfhttp://www.gmc-uk.org/FINAL_Report_prevalence_and_causes_of_prescribing_errors.pdf_28935150.pdfhttp://www.gmc-uk.org/FINAL_Report_prevalence_and_causes_of_prescribing_errors.pdf_28935150.pdf


10/10

26. Coles J, Pryce D, Shaw C.The Reporting of Adverse

Clinical IncidentsdAchieving High Quality Report-

ing: The Results of a Short Research Study. London,

UK: CASPE Research; 2001.

27. Waring JJ. Beyond blame: cultural barriers to med-

ical incident reporting. Soc Sci Med 2005;60:19271935.

28. Blegen MA, Vaughn T, Pepper G, et al. Patient and

staff safety: voluntary reporting. Am J Med Qual

2004;19:6774.

29. Broadhead RS, Fachinetta N. Drug iatrogenesis and

clinical pharmacy. The mutual fate of a social prob-

lem and a professional movement. Soc Probl1985;

32:425436.

30. Mesler MA. Boundary encroachment and task dele-

gation: clinical pharmacists on the medical team.

Sociol Health Illn1991;13:310333.

31. Weiss MC. Clinical pharmacy: uncovering the

hidden dimension. J Soc Adm Pharm 1994;11:6771.

32. Throckmorton T, Etchegaray J. Factors affecting in-

cident reporting by registered nurses: the relationship

of perceptions of the environment for reporting er-

rors, knowledge of the nursing practice act, and de-

mographics on intent to report errors. J Perianesth

Nurs2007;22:400412.

33. Kreckler S, Catchpole K, McCulloch P, Handa A.

Factors influencing incident reporting in surgical

care.Qual Saf Health Care 2009;18:116120.

34. Wakefield BJ, Blegen MA, Uden-Holman T,

Vaughn T, Chrischilles E, Wakefield DS. Organiza-

tional culture, continuous quality improvement,

and medication administration error reporting.Am

J Med Qual2001;16:128134.

Appendix

Focus group interview schedule

Part 1: Background [brief]

Can you tell me your current grade and the num-

ber of years that you have been qualied as

a pharmacist?

Part 2: Attitudes to medication error reporting [in

depth]

Prompts will be used to obtain more in-depth in-

formation as necessary

What does incident reporting/medication error re-

porting mean to you?

What system exists in your hospital for reporting

medication errors

Prompts: Does it work well?

Are there any problems with it?

Do you have a pharmacy intervention monitoring

scheme as well?

Do you record incidents in the medical notes?

What do you think is an ideal reporting system?

Are you clear what to report?

Prompts: Any differences between near misses

and actual incident?

Does the severity of the incident make any differ-

ence? Use example

Are you expected to report all medication errors?

What dictates whether you actually do or dont

report a medication error you come across?

What do you think is the primary purpose of re-

porting medication errors?Prompts: If we dont report errors how do we

spread the message that occurred and work out

how to reduce likelihood of happening again?

Should it not be for the greater good?

Are you happy to report medication errors?

Prompts: Any fears and if so what of?

Any differences between self-reporting and re-

porting others?

Any cultural issues?

Issues about anonymity?

Can you give me any positive or negative exam-ples of reporting?

Prompts: Any changes made (or not made)/les-

sons learnt because of an incident?

What do you think patientsviews would be about

whether pharmacists report medication errors?

Prompts: Are you motivated to report for the ben-

et of patients?

How often do you report medication errors?

Why is that hospital pharmacists dont report

medication errors very well? Are there any other barriers to reporting medica-

tion errors?

Prompts: Any physical barriers, for example, time

to ll out or ease of form.

Concluding part

Is there anything else you would like to talk

about? Or anything you would like to go back

to or add?


pharmacist attitude

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