Factors influencing hospital pharmacists reporting of medication errors

Abstract

Over a decade ago, the Institute of Medicine report “to err is human” focused widespread public and healthcare attention on avoidable patient harm from medication misadventure. Subsequently, the reporting of medication errors has become established as a principal safety initiative to inform strategies to reduce patient harm. However the under-reporting of error compromises this objective, with international estimates suggesting less than 1% of errors are reported. Within Australia, hospitals pharmacists’ are often central to the coordination and implementation of medication safety improvements. As a result, the under-reporting of error by pharmacists’ is likely to be an important omission in our ability to understand and minimise harm. Despite earlier research assessing the attitudes of other health professions, little is known about the factors influencing hospital pharmacists’ reporting of medication error. Our investigations have included the identification of key modifiable barriers to error reporting and the development and implementation of a streamlined web-based error reporting system to mitigate these key disincentives. This reporting tool produced a sustained increase in pharmacist initiated error reports, enabled quantification of the frequency of under-reporting, and a more detailed understanding of the ‘nature’ of errors as perceived by pharmacists’. However, there was wide variation in the use of this streamlined reporting tool even after accounting for a range of factors identified as influencing its use in the workplace. These observations generated further investigation into the contribution of ‘non-traditional’ drivers of variation in practice, such as ‘profiling’ of individual pharmacists’ error reports, and perspectives of workplace ‘safety culture’. 12 In our investigation across a range of public hospitals we observed that hospital pharmacy staff identify with a positive safety culture, with this overall perception influenced by factors including; hospital type, professional group (within pharmacy) and by individual staff affiliation with professional organisations. Participants ‘decisively’ reported a positive culture for ‘identifying the causes of safety incidents’ and ‘incident reporting’ but there remained significant individual variation in reporting behaviours. Upon exploring clinical practice variation further, we identified more complex and diverse individual ‘profiles’ of pharmacists’ medication error reporting than would have been expected from the commonly reported ’overview’ of medication error reports. Taken collectively our investigations support aspects of earlier research from the medical and nursing professions, with traditional workplace factors influencing hospital pharmacists’ reporting of medication error. However, there remains significant variation in clinical practice with is not fully explained by functional aspects of the workplace or its safety culture. These findings provide a rationale for further investigation into non-workplace factors that drive individual behavior, such as; personality ‘traits’, beliefs and values, and their influence on medication error reporting.