Background
Method
Group | Pharmacists | Pre-registration pharmacists | Support staff | ||
---|---|---|---|---|---|
Owner | Employed | Locum | |||
1 | 1 | 6 | |||
2 | 2 | 4 | |||
3 | 7 | 1 | |||
4 | 4 | ||||
5 | 9 | ||||
6 | 1 | 3 | |||
7 | 4 | ||||
8 | 2 | 3 | 1 | 1 | |
9 | 10 | ||||
10 | 8 | ||||
Total N | 10 | 11 | 31 | 10 | 5 |
% of sample | 14.9 | 16.5 | 46.3 | 14.9 | 7.4 |
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What are the attitudes and views of pharmacists and support staff about patient safety in community pharmacy?
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What is the prevailing culture with respect to patient safety in community pharmacy?
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How does the prevailing culture affect how incidents are handled?
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What types of incidents are reported/not reported in community pharmacy?
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What factors facilitate and inhibit reporting?
Results and discussion
General themes | Subordinate themes |
---|---|
(i) Relationships involving the pharmacist:
| |
Peers | Group norms |
Involvement of locums | |
Other health care professionals | Collaboration with prescribers |
Pharmacist involvement in governance | |
Patients/customers | Customer demands |
Trust in pharmacist | |
Patient as final safety barrier | |
Informing patients about safety issues | |
(ii) Demands on the pharmacist:
| |
Commercial | Profitability vs safety |
Financial dependencies | |
Budgetary constraints | |
Corporate | Approach to governance |
Organisational culture | |
Hierarchy and protection | |
Legal and regulatory | Legal and regulatory sanctions |
Following the law vs meeting demands | |
Support from regulator | |
Regulator enforcing standards | |
(iii) Management and governance:
| |
Blame culture vs learning culture | Allocating/accepting blame |
Learning from experience | |
Openness and trust | |
Being the target of blame | |
Formal vs informal processes | Monitoring and audit |
Reporting and feedback | |
Trust and engagement in governance | |
Communities of practice | |
Protocols | Quality assurance |
Individuality and professional autonomy | |
Credibility and practicality | |
Doing what's best for the patient | |
Work design | Human-computer interaction |
Workspace | |
Automation |
Relationships involving the pharmacist
Peers
[We] were taught, certainly in my era, at College, you did not make mistakes, you covered them up, that was the history. I had a boss who I could have killed because he did make mistakes but he refused to admit it. [...] [I] went in to the dispenser and said "Look, ignore him, we all make mistakes, we check each other" [Locum pharmacist, Group 9]
I [once] had an issue with methadone, [...] I did not agree with what the pharmacists had done the previous week and they'd done nothing about it all week when they had time to sort it out and then they didn't even tell me in advance of me going, I walk in on the Saturday and get stuck with the real issue, do you give it, don't you give it. And you're dealing with something that's quite, you know, can change that person quite a lot, and you're thinking, "Well, where do you stand?" [Locum pharmacist, Group 3]
Other health care professionals
When a prescription comes into us we're relying on the fact that the GP has made the correct diagnosis and has prescribed a dose that is safe for that patient. [...] So [...] you're already working, even with prescription medicines, from half the song sheet, aren't you? [Pharmacy owner, Group 10]I would send [an incomplete prescription] back even if I knew the doctor. If you accept it the first time and you keep accepting it, [...] it'll happen again. [...] I'm just not going to accept the responsibility for the doctor's mistake. [Locum pharmacist, Group 1]
Patients/customers
I [once] called the name, didn't ask the address, spent ten minutes counselling [the patient] on how to use an inhaler and [he] came back and said "This is the wrong thing. I was expecting tablets". [...] That was my mistake, [but] that goes to show you how much he was listening [Locum pharmacist, Group 1]We want to [...] expand our role, and if the patients aren't gonna have any confidence in us in like medication reviews and prescribing, if they think we're not as competent [...]. That's my concern, I just don't want them to lose confidence in us because I want pharmacists to do those extended roles [Employed pharmacist, Group 4]
I think we've got to get away from the idea that a good pharmacist in the view of the public is one who gets the medication out quickly. [...] They just assume that it's going to be correct but they don't rank the actual quality of the dispensing in any of it, they put speed at the top [Locum pharmacist, Group 9]I've got an open plan pharmacy, and I've got people right over the top and talk about interruptions. [...] It takes your whole attention away. [...] The patient can be the biggest distraction you have [Pharmacy owner, Group 10]
Demands on the pharmacist
Commercial
We're gonna be [...] competing for money [from the Primary Care Trust] cos they're gonna have seventy five percent of the budget and [...] we're gonna want their services, so it might prevent us from being honest [with them] about our mistakes and errors [Employed pharmacist, Group 4]It's very hard to make it work when you've got [...] whistle-blowers in two different sorts of organisation. Like non-profit organisations like nurses and GPs, and pharmacists in profit organisations, we're supposed to whistle-blow on GPs if we see bad prescribing, but to the detriment of our business? [Pharmacist, Group 8]Staff is the single most expensive item in any business, whether it be pharmacy or anywhere else, and all the firms [...] are under pressure from their shareholders to make more profit, and the easiest and quickest way to do that is not increasing turnover, it's to cut down the staff [Locum pharmacist, Group 9]
Corporate
I think the protocols that [chains] have as well tend to be stricter [than in independents], and they won't let you bend from the protocols [Employed pharmacist, Group 6]No, because they've got so many branches to cover, they've got to put it down as a must do, rather than a, well, we'll get round it type of thing [Locum pharmacist, Group 6]The advantage of notifying the Head Office [of a chain] is that they then cascade the information to everybody so that every store can then separate the Xalacom and Xalitan in the fridge so that it doesn't happen, so you're actually avoiding the error ever happening [Locum pharmacist, Group 9]I think you tend to get more demoralised staff in a company and more negative on feedback and communication to a well run independent sometimes, because I think they're sort of all put into a block and they can be boxed if you're not careful in a company [Locum pharmacist, Group 1]
Legal and regulatory
Getting struck off the register, the thought of that, and as a professional as well, not being able to practice. So it's all kinds, you have a lot to lose as a pharmacist [Employed pharmacist, Group 4]It's all about going to court, isn't it, that's the last thing anybody wants [Employed pharmacist, Group 4]You get somebody coming back and say, [...] "I was owed five bendrofluazide tablets." And there's absolutely no record [...], somebody's [must have] made a mistake at this end [...], so [...] you give it out. Now, technically that's going against the law [...] [but] at the end of the day there's a little bit of a grey area [Locum pharmacist, Group 6].The pharmaceutical inspector [...] had a woman who was on fentanyl patches [...]. The pharmacist actually lent her a pack of five, on the understanding that the [...] surgery [was] going to write the prescription. [...] [However, the] surgery would then not provide a prescription. [...] [The inspector] said there was no way I was going to jump on him for giving those five patches which she'd been having for [...] seven or eight months, because the pharmacist had done the right thing by the patient [Locum pharmacist, Group 6]
We've been calling for [manufacturers to change] the packaging and colour [coding] and all the rest of it, we've been calling for this for years, and nothing's happening because [...] no individual body has got sufficient clout, so it needs to go to one central body to actually be able to say "Enough is enough" [Locum pharmacist, group 9]
Management and governance
Blame culture vs learning culture
One of the issues [...] is getting rid of this blame culture. Although we're trying to instil [that] it doesn't really matter who did it, [...] let's move on and learn from it, people are still very hung up on who actually committed the error [Locum pharmacist, Group 9]Even in our branch they say it doesn't matter if you've done wrong, [...] just write your name down here but nobody likes their name put down. [...] You get a bit paranoid, you think [...] it's just your name there and you think you must be absolute rubbish at your job [Pre-registration pharmacist, Group 5]
Formal vs informal approaches
Newly qualified [...], couple of days in, made a mistake, and I told them and we talked about it, but I didn't report it to head office, cos I knew that they were devastated [...] I gotta think about this person and they would probably not wanna be a pharmacist any more. [...] My thought [was that] they really learnt from this, and I would be surprised if they did it again [Pharmacist, Group 2]If your reports are gonna go "Look, this pharmacy's got this much near misses, ooh, it's a black-listed pharmacy, this one." But if they're gonna [...] recognise that you've got these amount of near misses or whatever, this is what you could do, this what you could do to improve. [...] Is it gonna be against you or for you in that respect? [Pharmacist, Group 8]There's no point in being proactive to a system or management or a body which is itself being reactive and disciplinary, because that defeats the point of you being proactive in the first place [Pharmacy owner, Group 10]
Protocols
The protocols are set up because that gives the best chance of success and the best patient outcome, now you can still have a good patient outcome even though the protocol's not been adhered to, but [that could be by] luck [or] whatever [Pharmacy owner, Group 10]I know other pharmacists who [...] definitely stick to the rules, no matter what, and are not gonna bend 'em. Then some people who kind of just squeeze past them. So it does depend on the person [Pharmacist, Group 2]If you've got a patient who's at risk and if you're doing something or not doing something, then I would ignore [the protocol] and do what I thought was the professional way, would be the best thing to do [Pre-registration pharmacist, Group 5]I sometimes think they're not very helpful for patients. If you've got a protocol and you've got to do it a certain way, but then you can't, say a checking one [...] do you break it for the benefit of the patient, even though you know you shouldn't? [Pharmacist, Group 2]
Work design
If you've got [...] [a] layout [in] which you're literally right behind the sales counter you can eavesdrop on pretty much any conversation, if you've got somebody at the far end of the shop ringing a bell every time [they're selling] a bottle of Calpol, then you're less able to intervene [Pharmacy owner, Group 10]The "goldfish bowl" dispensary is not a good thing [Locum pharmacist, Group 9]You've got to have a tidy dispensary or things do get muddled up and then when you're working fast you're just leaping around, grabbing things off the shelf, and unless things have been put in the correct place it's so easy [to make a mistake] [Locum pharmacist, Group 9]If you start looking at the dispensing process as two stages, there's the mechanical process and there's the clinical process. [...] [If] you divest the two and use [automation] to take away some of the human error [...] while still allowing the clinical input [...] you stop worrying so much about "Am I gonna make errors that are gonna go out to the patient?" [...] That becomes less of an issue and you start thinking more about "Hang on a minute, is what's being dispensed in the best interest of the patient anyway?" [Pharmacy owner, Group 10]