The value of community pharmacy incident reporting in optimising the safety and quality use of medicines

Abstract

Medication safety has emerged as a healthcare priority with the launch of the World Health Organization’s third global patient safety challenge. Understanding the complex interplay between human and system factors that potentiate medication incidents can illuminate improvement opportunities in organisational safeguards and safe medication practices. This thesis aimed to develop, implement, and evaluate systematic incident reporting system (IRS) to identify, characterise and address risks to medication safety and quality use of medicines (QUM) in primary care. The study was conducted in 30-community pharmacies in Sydney, Australia, through a confidential and anonymous IRS called QUMwatch. The study used the Advanced Incident Management System (AIMS) taxonomy, which is a hierarchical classification system based on error theory. Analysis of 1,013 incident reports collected over 30 months, identified medication incidents (MIs) that affected patients over 65 years old, the prescribing stage, and medicines acting on the cardiovascular and nervous systems. Human, task, and organisational factors contributed to MIs, particularly healthcare providers' cognitive errors, communication problems, poor risk management, and safety culture. Factors that facilitated error recovery included individual attributes, appropriate intervention, effective communication, and the use of standardised protocols. Remedial actions included changes in care plans, dosages, reviews of medicines, and medicine cessation. The study evaluated the QUMwatch program's tools and methods using a mixed-methods approach and found that 16 out of 20 variables on the data collection form had over 90% complete data, and data consistency was high. Anonymity was the preferred method of reporting. The stimulatory package significantly raised the reporting rate from a baseline average of 32.4 to 77.3 reports/month (p < .001). The AIMS taxonomy for MIs had substantial validity for high-order medication processes for the Australian community pharmacy context. The study demonstrated the feasibility of a well-designed IRS in community pharmacy to identify MIs and to generate safety lessons and recommendations.