Assessment of patient safety culture: a nationwide survey of community pharmacists in Kuwait

Patient safety, defined as “the freedom from accidental injuries during the course of medical care; activities to avoid, prevent, or correct adverse outcomes which may result from the delivery of healthcare [1]” is a critical element of healthcare quality and has been a public concern across all healthcare systems worldwide. Medication errors, defined as “any preventable events that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer” [2], are a common component of medical errors threatening patient safety [2, 3]. They are estimated to be the 8^th leading cause of death in the US and are responsible for the death of approximately 44.000 to 98.000 people every year [1, 4]. While all medication errors are preventable, 28% of Adverse Drug Events (ADE), defined as “injuries resulting from medical interventions related to a drug” [2], are preventable and pharmacists can play a pivotal role in preventing 50% of them [5]. Studies have shown that pharmacist intervention can help to improve patient safety and quality of care [6, 7].

Promoting a “culture of safety” within healthcare systems has become one of the major pillars for optimizing patient safety. Following the report from the US Institute of Medicine (IOM) in 1999 [1], there has been a growing recognition within the healthcare systems of the need for transforming an organizational culture to improve patient safety. The safety culture of an organization is the product of individual and group values, attitudes, perceptions, competencies, and patterns of behaviour that determine the commitment to the style and proficiency of an organization’s health and safety management [4]. Achieving a culture of safety requires an understanding of the values, beliefs and norms regarding health and safety within an organization, thus it is vital to unveil the underlying cultural factors present within the organization so that safety culture can be transformed [8, 9]. Frameworks, surveys and assessment tools have been designed over the past decade to measure and understand the type of culture that exists within healthcare organizations and to identify the areas of strengths and gaps [8, 10‐14].

On a global basis, several international health bodies, such as the World Health Organization (WHO) and the Joint Commission International (JCI) advocate measuring safety culture within healthcare organizations as an effective strategy for sustainable safety improvement. A recent systematic review assessing the status of patient safety culture in the Arab countries called for the need to promote patient safety culture for improving patient safety in the Arab World [15].

There has been an intensive effort by the Ministry of Health (MoH) in Kuwait to ensure that the healthcare delivery meets the international standards. Accreditation Canada International (ACI) was commissioned in Kuwait to introduce a national accreditation program to be adopted by government hospitals and polyclinics [16]. On the other hand, the community pharmacy setting had less attention and therefore conducting this study is of utmost importance to explore the status of patient safety and to call for recommendations wherever necessary.

Few studies on safety culture were published in Kuwait [17‐19]. However, none were surveyed among community pharmacists. To the best of our knowledge, this is the first study in the Middle East conducted in the community pharmacy setting to evaluate whether the practice of community pharmacists support patient safety and the extent to which safety is a strategic priority.

A total of 255 community pharmacists from the five governorates were approached to participate in the study, of whom 253 have returned the completed questionnaire, giving a response rate of 99%. The sociodemographic characteristics of the participants are shown in Table 1.

This study is the first of its kind in Kuwait to report data on the community pharmacists’ perspectives of patient safety culture in their practice. Furthermore, the third publication of its kind using the PSOPSC to explore patient safety culture in the setting of community pharmacies [21, 22], following the piloting of the questionnaire in 60 US pharmacies approximately 6 years ago during the development of the study tool [23]. Although many questionnaires were developed to assess patient safety culture, they are generally focused toward healthcare organizations as a whole and are not customized to specific departments within an organization [13]. PSOPSC is a very comprehensive survey and community pharmacy specific.

The response rate in the present study was 99.0%, which was higher than that of previous studies [17‐19, 24, 25], including the study in Malaysian retail pharmacies (93.52%) [21] and the AHRQ study (75.0%). The higher response rate in the study can be due to the fact that the questionnaires were distributed in-person by the researcher. This contrasts to online surveys used for data collection in the previous studies [25, 26]. Many community pharmacists were requested to complete the questionnaire during the overnight shifts when pharmacists did not have much customers, hence, they had sufficient time to fill out the questionnaire.

For the 36 items of the questionnaire, an overall mean of 83.3% was scored for patient safety culture which is higher than that in earlier studies conducted in Malaysia [21] and China [24] . This reflects that the pharmacists working at the community pharmacy understood the importance and values of patient safety in their practice. Findings in the current study also showed that there was a significant variability in the PRR values across the dimensions of patient safety. In line with other local [17‐19] and international studies [21, 27], the highest PRR was seen in the “Teamwork” domain (96.8%), suggesting that the concept of teamwork is universally positive in the practice of pharmacy. This was followed by the domains of “Organizational Learning-Continuous Improvement” and “Patient Counselling” scoring 93.2 and 90.9% respectively, which highlight the existence of a learning culture among practicing pharmacists to improve the services which in turn can enhance the patient safety. In addition, patient counselling is the core of pharmacy practice in the community pharmacies in Kuwait and community pharmacists expressed their engagement and willingness to spend enough time with patients to discuss about their medications. With this respect, studies have shown that community pharmacists’ interventions can reflect positively on patients’ adherence to medications and subsequently their therapeutic outcomes [28].

The lowest PRR was given to the “Staffing, Work Pressure, and Pace” domain which scored 49.7%, close to the study from Malaysia [21]. In particular, the frequent interruptions or distractions in the pharmacy, feeling rushed when processing prescriptions and inadequate breaks during shifts were given the lowest PRR of 27.1, 38.5, and 42.3%, respectively. In addition, pharmacists working for more than 40 h per week had significantly lower PRR on the adequacy of breaks during shifts (Table 6). The environment of the pharmacy was a significant factor related to medication errors [29‐31] and increased dispensing errors were reported where there was unfavourable working environment [32]. Taking this into account, all community pharmacists in Kuwait and elsewhere should be supported by a favourable workplace to allow them to work more efficiently.

At the level of governorates, there was a significant discrepancy in responses of community pharmacists from the five governorates on some items of the “Staffing, Work Pressure, and Pace” domains. Although the majority agreed that the pharmacy had enough staff, the Capital and Hawalli governorates scored the lowest in the items of pharmacists feeling rushed when processing prescriptions and having frequent interruptions, while Farwaniya, Jahra and Ahmadi had the lowest scores with regards to inadequate breaks during shifts. This could be partly explained by uneven proportion of the community pharmacy distribution across governorates as opposed to population number. For example, according to the last published Annual Health Report of Kuwait [33], Farwaniya was the most populous governorate, with a population size of 1,032,082, followed by Ahmadi, Hawalli, Capital and lastly Jahra. In comparison, the total number of community pharmacies in Farwaniya region was 89 (as compared to 160 in Hawalli, 109 in Ahmadi, 48 in Capital and 48 in Jahra) according to the data obtained during the preliminary fieldwork from the MoH, Kuwait in 2017. Therefore, results from the study suggest the need for accurate planning for the distribution of community pharmacies in Kuwait, and in other countries, to target the population size in each region.

The “Communication about Prescriptions across Shifts” and “Communication about Mistakes” dimensions showed relatively lower scores of 74.6 and 81.8%, respectively, which indicates the need for improvement. In dispensing medications, effective communication is crucial to minimize drug related problems. Pharmacy staff should learn from each other’s by knowing their own responsibilities as well as engaging in discussing mistakes and providing feedback. The mutual understanding among working staff on patient safety issues and knowledge on sources of mistakes and ways of detecting and preventing them will enhance the patient safety [34]. Also, results from the study showed that regardless of their seriousness, there was a minimal documentation of mistakes carried out in the community pharmacies. The MoH in Kuwait should have a proactive role in setting specific policies and guidelines for strategies that should be followed when identifying and communicating mistakes, similar to other international communities [35].

The work experience level and length of working hours are closely related to the relative occurrence of the patient-related risk events [36‐38]. This study tested pharmacists’ PRR on safety culture items in respect to experience years and working hours per week. Pharmacists with more work experience (a minimum of 6 years of experience) scored better PRR for items relevant to adequacy of training and breaks during shifts. This could be related to the fact that their seniority in work allowed them to master pharmacy workload and tasks more than those with less years of experience. In line with this, senior pharmacists in the study by Jia et al. [24] gave significantly higher PRR scores on the item of staff taking adequate breaks during shifts. These results suggest the importance of providing less experienced community pharmacists with adequate training and breaks during shifts to handle workload and to minimize errors.

Understanding patient safety culture from the perspectives of community pharmacists can help identify areas of weakness and can support decision for improvements. Our results suggest that pharmacies in Kuwait should develop strategies and plans to improve aspects of patient safety such as communication about prescriptions throughout shifts and responses against mistakes and create a positive culture that encourages patient’s safety in this setting. Urgent attention should be given to the areas of weakness in the patient safety, which has been observed mainly in the dimension of Staffing, Work Pressure, and Pace. With this respect, stakeholders should undertake the required steps towards supporting community pharmacists with adequate number of staff and with organized less distractible environment in order to perform their work accurately without jeopardizing patient safety.