Original ResearchUnderstanding the attitudes of hospital pharmacists to reporting medication incidents: A qualitative study
Introduction
The interest in health care adverse events (errors/incidents) has increased substantially following the publication of the Institute of Medicine’s (IOM) “To err is human” report in the United 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 estimates 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 extensively studied in general medical/surgical care6, 7 and across a wide range of specialties including obstetrics,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 personal fears 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 medicine use process are very different to medical and nursing colleagues, which may mean that their attitudes 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 consequences for the pharmacist involved in the error, appear to be the overriding attitude of pharmacists to reporting medication errors.15, 16, 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 reporting system or document the incident as a “pharmacy intervention,” as it affected their annual appraisal.15 Staff were formally rewarded at appraisal for interventions made, but formally recorded incidents involving themselves were used to compare staff with their peers. The department promoted a nonpunitive culture but staff perception of that varied and pharmacists 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 regional medication error reporting system, where the 14 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 medication 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 likelihood of reporting adverse events with 275 UK community pharmacy staff revealed a lack of understanding 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 dispensing or supply of a medicine, and whether the behavior of the community pharmacist involved compliance (in line with protocol), violation (deliberate deviation from protocol), or error (not being aware of a protocol) were presented but participants were found to be unlikely or very unlikely to report any of the events to a local, or the national, reporting scheme.
More recently, Boyle at al18 considered the attitudes to medication incident reporting in a Web-based survey involving 72 community pharmacy staff in Canada. Pharmacists, pharmacy managers, and pharmacy technicians were somewhat ambivalent about the impact on day-to-day operations, the ease of completion of current reporting systems, and the personal support given to individuals involved 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 incidents, in addition to the need for appropriate training 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 anonymity 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 unknown, yet in the recent EQUIP study the prevalence of prescribing errors alone in UK hospitals was 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 being voluntarily reported via the hospital’s incident reporting system (P. Lewis, EQUIP researcher, personal communication, 10th August 2011). Similarly, a direct observation of medication administration in 36 U.S. hospitals revealed an 11.7% error rate compared with just 0.04% for errors detected through the incident reporting scheme.20
If the benefit of reporting errors is for organizations 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 accomplish this. This may therefore be inhibiting the ability 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 pharmacists do not appear to report medication errors that occur is therefore warranted, particularly as there is also emerging evidence that better voluntary incident reporting per se is associated with a more positive patient safety culture in hospitals.21
Section snippets
Methods
Ethical 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 negatively in a previous survey exploring the attitudes of pharmacy staff to patient safety climate.22
Lead clinical pharmacy managers in the 4 hospitals
Results
The characteristics of the pharmacists recruited from the 4 hospitals who took part in the focus groups are shown in Table 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 in line with UK-hospital pharmacy workforce data.25
Three out of the 4 hospitals used paper incident reporting forms and 1 had a fully electronic incident reporting system. The 3 hospitals with paper forms had 2 different types of error reporting
Discussion
This study’s 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 for patients 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 reporting medication errors that appears unique to
Conclusion
Hospital pharmacists understand the importance of reporting medication incidents to improve patient safety, but due in part to the number of errors they encounter, they do not 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 an error is a complex process for
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