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Research Paper International Journal of

Pharmacy Practice International Journal of Pharmacy Practice 2014, ••, pp. ••–••

An exploration of Australian hospital pharmacists’ attitudes to patient safety Daniel J. Lalora, Timothy F. Chenb, Ramesh Walpolab, Rachel A. Georgeb, Darren M. Ashcroftc and Romano A. Foisb a

Medication Safety, Clinical Excellence Commission, bFaculty of Pharmacy, The University of Sydney, Sydney, NSW, Australia and cCentre for

Pharmacoepidemiology and Drug Safety Research, School of Pharmacy and Pharmaceutical Sciences, University of Manchester, Manchester, UK

Keywords clinical pharmacy; clinical practice; drug utilisation; medicines management; patient safety Correspondence Mr Daniel J. Lalor, Medication Safety, Clinical Excellence Commission, Level 13, 227 Elizabeth St, Sydney, NSW 2000, Australia. E-mail: [email protected] Received February 28, 2013 Accepted March 2, 2014 doi: 10.1111/ijpp.12115

Abstract Objectives To explore the attitudes of Australian hospital pharmacists towards patient safety in their work settings. Methods A safety climate questionnaire was administered to all 2347 active members of the Society of Hospital Pharmacists of Australia in 2010. Part of the survey elicited free-text comments about patient safety, error and incident reporting. The comments were subjected to thematic analysis to determine the attitudes held by respondents in relation to patient safety and its quality management in their work settings. Key findings Two hundred and ten (210) of 643 survey respondents provided comments on safety and quality issues related to their work settings. The responses contained a number of dominant themes including issues of workforce and working conditions, incident reporting systems, the response when errors occur, the presence or absence of a blame culture, hospital management support for safety initiatives, openness about errors and the value of teamwork. A number of pharmacists described the development of a mature patient-safety culture – one that is open about reporting errors and active in reducing their occurrence. Others described work settings in which a culture of blame persists, stifling error reporting and ultimately compromising patient safety. Conclusion Australian hospital pharmacists hold a variety of attitudes that reflect diverse workplace cultures towards patient safety, error and incident reporting. This study has provided an insight into these attitudes and the actions that are needed to improve the patient-safety culture within Australian hospital pharmacy work settings.

Introduction While the concept of patient safety is as old as the Hippocratic Oath, the issue has received far greater consideration since around the turn of this century when a number of landmark publications were released highlighting deficiencies in the provision of health care. These publications included An Organisation with a Memory,[1] ‘The Quality in Australian Health Care Study’,[2] and the US Institute of Medicine report, To Err is Human: Building a Safer Health System.[3] Specific issues related to medication safety were brought to the fore in Australia through the 2002 release of the Second National © 2014 Royal Pharmaceutical Society

Report on Patient Safety: Improving Medication Safety.[4] Since then, considerable efforts have been made to improve the safety of medicines use within hospitals, and pharmacists have led much of this work.[5,6] Measuring the safety of systems for medicines use or the impact of interventions to improve medication safety is challenging and various methods have been employed.[7] Data from incident reporting programs and sentinel events have been used but are not intended for quantitative rate measurement.[8] Incident reporting programs are largely voluntary in International Journal of Pharmacy Practice 2014, ••, pp. ••–••

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nature, and the incidents captured through these reporting programs have been shown to be only a small fraction of incidents that occur.[9] As a result, false conclusions can be made about the safety of a system if this safety is measured using incident data. Trigger tools can provide measures for specific indicators, facilitated now by the introduction of electronic systems where data are freely available,[10,11] but questions have been raised about the reliability of trigger tools.[12] Chart review provides some degree of accuracy[13] but is labour intensive. These methods can provide valuable information about weaknesses in the systems for medicines use and provide direction with respect to undertaking system improvements. However, merely collecting data about system weakness does little to improve the safety of medicines use, and it is the response to this information that is crucial to improving medication safety. It is a positive and constructive response to error that creates a safer system.[14] An organisation’s safety culture is considered to be one of the key factors that determine how incidents are responded to and how likely it is that the same incidents will recur.[14] This safety culture is widely understood to be the shared beliefs and values of employees within an organisation that result in their displayed behaviours and attitudes related to safety. These displayed behaviours and attitudes are the measurable features of a safety culture and are referred to as safety climate.[15,16] Safety culture is frequently more colloquially described as ‘the way we do things around here’.[17] Various methods have been employed to measure safety culture or safety climate within health care organisations.[18–20] Understanding and improving this safety culture have been shown to be of benefit to patients, and links have been drawn between a positive safety climate and improved patient outcomes[21,22] and experiences.[23] Hospital pharmacy departments are often central to the coordination and implementation of medication safety improvements in Australian hospitals. Consequently, understanding various aspects of the safety culture within the practice setting of hospital pharmacists is likely to be important to medication safety in Australian hospitals. Knowledge of the attitudes of pharmacy staff to patient safety, error and incident reporting is valuable information. These attitudes represent the patient-safety culture within the work settings of Australian hospital pharmacists and can inform efforts to further develop this culture. The objective of this study was to explore how Australian hospital pharmacists view patient safety within their work settings. This study formed part of a larger body of work exploring safety climate among Australian hospital pharmacists. This larger study used a questionnaire to collect both structured and free-text information. This paper explores the attitudes of Australian hospital pharmacists as expressed in the freetext comments collected. © 2014 Royal Pharmaceutical Society

Australian hospital pharmacists and patient safety

Methods Pharmacists’ attitudes about patient safety, error and incident reporting were collected through a free-text section of a safety climate questionnaire administered to active members of the Society of Hospital Pharmacists of Australia (SHPA). Thematic analysis was used to explore the main attitudes expressed by the participants.

Ethical review and personal information Ethical approval to conduct the study was granted by The University of Sydney Human Research Ethics Committee, and permission was granted by the federal secretariat of the SHPA to use the contact information of its members for recruitment purposes, in accordance with the Society’s privacy policy.

Survey instrument and data collection A study-specific questionnaire was constructed, based upon the Pharmacy Safety Climate Questionnaire[19] previously used in community pharmacy in the UK. Modification of the questionnaire was undertaken by the research team to ensure relevance of the questionnaire to both the Australian and hospital settings. The modified tool was also reviewed by a small number of hospital pharmacists. The specific safety climate questionnaire used in this study comprises four main sections: (A) a section for providing an overall grade on patient safety (using a 5-point Likert scale); (B) a quantitative section of 42 Likert-scale items based on the Pharmacy Safety Climate Questionnaire;[19] (C) a section on participant and hospital demographics; and (D) a free-text field for participants to provide comments on patient safety, error or incident reporting (Table 1). This manuscript pertains to

Table 1

Structure of hospital pharmacy safety climate questionnaire

Section

Data captured

Data format

A

5-point Likert scale (from excellent to failing)

C

Overall grade on patient safety for the hospital pharmacy Items adapted from patient-safety climate questionnaire[19] Demographic

D

Comments

B

42 items using 5-point Likert scale (from strongly disagree to strongly agree) Participant demographics (e.g. age, role, years of experience) and hospital details (e.g. state, size, location) Free-text comments about patient safety, error or incident reporting

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sections C and D of the questionnaire only. The results from the quantitative analysis of the survey items will be reported elsewhere. Between May and July 2010, an external data management company administered the questionnaire, by post, to all 2347 active members of the SHPA. Reply paid envelopes were provided with each questionnaire, which was coded for members’ identities by the data management company to enable follow-up by a second mailing of questionnaires to nonresponders after 3 weeks. After a further 7 weeks, the survey was closed and data were entered into a spreadsheet by the data management company and provided to the research team in a de-identified form.

Data management and analysis Hand-written, free-text comments were transcribed verbatim into a spreadsheet by an external data management company with experience in management of health data. Transcription was confirmed by a second staff member at the data management company and then data were provided to the research team as a spreadsheet. Thematic analysis was then undertaken. All free-text comments were reviewed and classified using an iterative process involving three members of the research team. The first stage of classification involved the first reviewer (DJL) reading all responses and compiling a list of major themes and subthemes portrayed. These themes were subsequently verified by the other two reviewers (RAG and RW). Response data were then reviewed a second time independently by each reviewer and were coded for thematic content according to the agreed themes. Coding was then compared for consistency and where discrepancies existed among the reviewers, discussion was held until consensus was reached regarding the major theme portrayed in the response. All three reviewers were registered pharmacists.

Results The attitudes of pharmacists presented clear themes that portrayed both facilitators of and barriers to a patient-safety culture (Table 2). The main themes discussed as barriers to patient safety were inadequate workforce and adverse working conditions, deficiencies in incident reporting systems and the evidence of a blame culture. The main facilitators discussed were an openness about and positive response to error, effective teamwork and a commitment to safety.

Sample characteristics A total of 643 responses to the survey were received, representing 27.4% of the 2347 SHPA members (after removal of © 2014 Royal Pharmaceutical Society

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Table 2

Respondent characteristics Number of respondents (n = 210)

Category Role in pharmacy Clinical Pharmacist Intern* Pharmacist Dispensing Pharmacist Pharmacy Technician Pharmacy Manager† Pharmacy Assistant Locum Pharmacist Other‡ Years of experience 0–5 years 6–10 years 11–20 years 21+ years Blank State New South Wales Australian Capital Territory Northern Territory Queensland South Australia Tasmania Victoria Western Australia Hospital location Metropolitan Regional/base Rural/remote Hospital size 10 or fewer beds >10 to 50 beds >50 to 100 beds >100 to 200 beds >200 to 500 beds More than 500 beds

Percentage of respondents

98 12 11 0 53 0 3 33

47% 6% 5% 0% 25% 0% 1% 16%

67 29 46 52 16

32% 14% 22% 25% 8%

59 4 4 39 17 13 61 13

28% 2% 2% 19% 8% 6% 29% 6%

149 52 9

71% 25% 4%

0 7 11 32 104 55

0% 3% 5% 15% 50% 26%

*An intern is a pharmacist who has completed his or her university degree and is undertaking supervised practice prior to examination by the registering authority and becoming a registered pharmacist. †A pharmacy manager is a pharmacist with responsibility for managing the pharmacy department, its services and/or its staff. This includes the director of pharmacy or the deputy director of pharmacy. ‡Pharmacists in the ‘other’ category work in specialist services such as medication safety, medicine information, community liaison, compounding, education, clinical trials, and quality control or identified themselves working across a number of roles.

all inactive members). Of these, 210 included free-text comments related to patient safety (32.6% of survey respondents and 8.9% of all active SHPA members). The characteristics of those providing comment were largely reflective of those of the Australian hospital pharmacist population as reported in the 2007 workforce snapshot[24] (Table 2). International Journal of Pharmacy Practice 2014, ••, pp. ••–••

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Australian hospital pharmacists and patient safety

Barriers to patient safety Workforce deficiencies Workforce issues emerged as presenting a significant barrier to patient safety. Pharmacists cited staff shortages and unrealistically high workloads as being particularly detrimental to safety. Patient safety is compromised by lack of funding to employ more pharmacists. Pharmacists in our hospital are stressed, overworked and trying to provide clinical services to way too many wards than is humanly possible. Errors happen as a result of this. (Respondent 119, Intern Pharmacist) I strongly feel the staffing levels are too low, the workload too high to promote optimum safety. Staff have trouble completing the basic daily workload, resulting in hurrying, stress and pressure which contributes to error. (Respondent 54, Clinical Pharmacist) Adverse working conditions Adverse working conditions, including dispensing environments that allow frequent interruptions and the lack of tools and equipment to support safety (such as barcode scanning devices), were also identified as barriers to safe practice. These barriers were also associated with the reported lack of support for pharmacy services from hospital management. I feel the major barrier to the development of solid safety culture in my department continues to be a lack of support and understanding from the hospital exec. (Respondent 58, Pharmacy Manager) An unwillingness was perceived among hospital management to spend money on safety initiatives and to support clinical pharmacy services. Deficiencies in incident reporting and management systems While incident reporting was acknowledged as a facilitator of patient safety, difficulty in the use of some electronic reporting systems was seen as detrimental to ongoing patient-safety efforts. The greatest challenge experienced with incident reporting was the time taken to report. Small numbers of incidents are reported due to complexity of [the incident reporting system] and time taken to enter incidents. (Respondent 153, Clinical Pharmacist) Another cited barrier to reporting incidents was the lack of feedback received once reports were made. © 2014 Royal Pharmaceutical Society

We don’t get feedback from AIMS (incident management system) or what has been done to avoid recurrence. (Respondent 167, Clinical Pharmacist) . . . In fact, as a notifier, you’re often unsure if anything has been done about it or if this electronic report is sent to an electronic abyss. This has a direct impact on reporting of an incident. (Respondent 197, Clinical Pharmacist) Additionally, concerns were expressed about the way in which medication incidents were responded to once they had been reported. There is a culture of reporting incidents, however nothing is ever done to improve the system to prevent incidents from reoccurring. (Respondent 183, Clinical Pharmacist) An incident occurred at our hospital and the pharmacist who made a mistake was very upset – management didn’t investigate, didn’t put any new safety processes in place and just told the pharmacist to ‘get over it’. When there is an attitude like this no-one mentions mistakes if it can be helped. (Respondent 11, Clinical Pharmacist)

Blame culture A culture of blame was identified as still existing in some workplaces: ‘. . . I have seen pharmacists “blamed” for errors and others fear what will happen to them if errors are reported to management . . .’ . (Respondent 168, Clinical Pharmacist) This also featured as a reluctance to submit incident reports for fear of affecting working relationships. Individually some persons may not want to be known as whistleblowers or troublemakers often intrinsic personalities, discouraging them from making valuable contributions. (Respondent 8, Dispensing Pharmacist)

Poor teamwork Barriers to teamwork within the pharmacy were identified and were seen as inhibitory to patient safety. A need was expressed for greater education of technicians in patientsafety issues and the role that they play in preventing errors. Technician staff have less awareness of patient safety issues and make many errors which are often fixed by pharmacists before reaching the patient . . . Training of our technicians about patient safety needs to be improved at my hospital. (Respondent 62, Clinical Pharmacist) International Journal of Pharmacy Practice 2014, ••, pp. ••–••

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Within the pharmacy department, pharmacists are concerned about reporting and patient safety issues. However, I feel that the technicians, especially at my hospital, don’t feel an ownership over reporting or that it is their role to do so. (Respondent 67, Clinical Pharmacist)

Importance of executive support A disconnect between the focus of pharmacy staff and pharmacy managers was reported. While frontline staff deals with patient-safety issues on a daily basis, those in management positions are seen not to appreciate the real issues or the implications of formulating top-down strategies. Many issues relating to safety are addressed by pharmacy managers and QUM pharmacists who have not practised clinical pharmacy for >5 years or have limited clinical experience. Introduction of new procedures/ schemes/processes to improve safety never involve any time analysis studies or evaluation of impact on work load. (Respondent 90, Clinical Pharmacist) Unfortunately most (senior) staff are very remote from the concerns of the department and think with a management point of view. (Respondent 172, Clinical Pharmacist)

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Support for incident reporting and response to errors Pharmacists also described details of open cultures where errors were freely discussed, reported and shared within the pharmacy and more broadly in order to highlight risks to patient safety. Errors in dispensing and shelving stock are reported at each fortnightly staff meeting as an education tool and to raise awareness – no names and no blame. (Respondent 134, Intern Pharmacist) This openness was also reflected by pharmacists who reported that the use of incident reporting and management systems was believed to have improved safety. Additionally, pharmacists described elements of incident review and subsequent systems changes that were not only important for addressing the specific incident reported but also for fostering a positive culture towards error reporting. . . . Timely review of an incident and feedback/ intervention at real time encourage staff to report more serious incidents and near misses, which often go unreported, and generate a positive culture among staff about patient safety, because they know that their concerns have been proactively dealt with . . . (Respondent 36, Safety and Quality Pharmacist) Effective teamwork

Facilitators of patient safety Pharmacists were also positive about efforts that have been made to improve patient safety, citing a number of factors that facilitate safer patient care. Perhaps not surprisingly, the facilitators of patient safety represent the opposite end of the spectrum of actions and characteristics within many of the themes identified above as barriers to patient safety (see Table 3).

Workforce allocation to patient safety Dedicated staff or dedicated time for staff to complete patient-safety activities was identified as an important driver. A full time medication safety pharmacist has lifted the profile of medication safety issues and supported a system rather than blame culture. (Respondent 1, Pharmacy Manager) . . . it means the ward pharmacists and managers are not trying to‘squeeze in’ medication safety work as well as doing their other jobs. (Respondent 84, Medication Safety Pharmacist) © 2014 Royal Pharmaceutical Society

Multidisciplinary engagement and teamwork was reported as a key success factor in supporting improvement in medication safety across facilities. Fostering good teamwork was, in part, seen to involve facilitating and encouraging communication such as speaking up when risks are identified. I work in a small department and we work collaboratively as a team and feel free to ‘speak up’. Sometimes the bosses at larger hospitals in network are more intimidating. Maybe because the more serious incidents are reported to them. (Respondent 84, Clinical Pharmacist) As a manager I’d like to think that we ‘pharmacists and techs’ all work together and I encourage the tech’s I work with to let me know about any of the mistakes I may have made. However, in reality I know when there has been serious mistakes made not by myself but other staff members, when I’ve tried to investigate the cause of the incident often I’ve had comments from the tech’s involved who said they didn’t feel able to question the pharmacist who’d already clinically checked the item. I think the only way we can overcome this in the future is to promote technicians clinical training, to give them the confidence to question things more thoroughly International Journal of Pharmacy Practice 2014, ••, pp. ••–••

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Table 3

Australian hospital pharmacists and patient safety

Themes that emerged from pharmacists’ comments

Barriers to patient-safety theme Workforce deficiencies

Adverse working conditions Deficiencies in incident reporting systems

Inadequate responses to errors

Presence of a blame culture

Subtheme Lack of dedicated staff to undertake medication safety activities Understaffing creating unsafe working conditions Inadequate training and development opportunities to improve performance Inadequate training in safety and quality Poor skill mix/lack of experienced staff Working conditions allow frequent interruptions Tools to improve safety not provided Physical working space that contributes to error Incomplete taxonomy Entering data is too time consuming Lack of training in incident reporting Low priority given to reporting of near misses and ‘trivial’ incidents No response to error Ad hoc/nonsystematic improvement efforts made after errors Inadequate feedback about error management discouraging reporting Incident reviews not producing adequate recommendations to prevent recurrence Blame culture leading to low morale

Facilitators of patient-safety theme

Subtheme

Workforce

Dedicated medication safety officer Clinical staff are dedicated to ensuring patient safety Professional development is supported and encouraged

Incident reporting

Electronic reporting system encourages incident reporting Reporting interventions increases the visibility of pharmacist contributions to safety

Response to error

Feedback on incidents and incident analysis facilitates reporting and an open culture Timely investigation is important Incidents used as opportunities for learning

Openness about error

Fear of being a ‘whistle-blower’

Commitment to safety

Teamwork

Lack of executive support

Education in patient safety has not overcome blame culture Some staff lack commitment to safety (pharmacy and other health care workers) Staff favour the status quo rather than taking a proactive approach to safety

Hierarchy in pharmacy prevents technicians speaking up Technicians not acknowledged as having a role in safety Lack of communication within the pharmacy team Disconnect in pharmacy team between decision makers and clinical pharmacists Lack of support from hospital management for safety and quality initiatives Cost of safety considered too high Key performance indicators and pharmacy metrics focus on work throughput not safety Private hospital funding model discourages a focus on safety and quality

Commitment to safety

Teamwork

Focus of investigation is process improvement Standard review processes assist investigation Errors are discussed in staff meetings in nonpunitive way Incident data are reported through hospital committees Newsletters and publication of incident data highlight areas for action Core of staff committed to improving safety Management who are constantly vigilant Committed leadership team Management support for project work and improvement activity Multidisciplinary engagement and teamwork enhances safety efforts Small collaborative teams enhance communication and speaking up Peer support enhances safety Team building enhances motivation

Inadequate scrutiny of errors made within pharmacy

© 2014 Royal Pharmaceutical Society

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with the pharmacists they’re working along side. (Respondent 5, Pharmacy Manager)

Strategies to improve patient safety Beyond the barriers and facilitators to patient safety discussed above, suggestions were provided for further improving safety. These included the use of double checking systems within the pharmacy, use of pharmacists to provide medication safety education for all disciplines within the hospital, the implementation of a national incident reporting and management system, and the development of standards of practice for reporting and managing medication incidents.

Discussion Comments made by Australian hospital pharmacists about patient safety, including error and incident reporting, revealed a significant amount of information about their attitudes to patient safety, the barriers that still exist to the provision of safe care and what they see as being supportive of patient-safety practices. The main themes discussed by pharmacists included the positive benefits of incident reporting systems as well as their deficiencies, the impact that workforce shortages has on patient safety, the importance of teamwork within the pharmacy and with other professions, the existence of a blame culture in some pharmacies and the need for executive support for safety. This study explored, for the first time, the attitudes of Australian hospital pharmacists to patient safety, error and incident reporting. The study participants were representative of the Australian hospital pharmacist workforce and provided a rich data set that encompassed the views of pharmacy managers as well as clinical pharmacists and intern pharmacists. Given the anonymous nature of the information provided, pharmacists were able to provide honest and frank information about patient-safety issues within their pharmacy departments and hospitals more widely. However, this data set is limited as it was obtained as a component of a wider, questionnaire-based study. Our data emerged from a subset (8.9% of SHPA membership) of those pharmacists who responded to the survey questionnaire (27.4% of SHPA membership). While this may limit the extrapolation of the quantitative survey results, this qualitative analysis identifies among Australian hospital work settings important characteristics perceived as supporting or impeding patient-safety practices. As free-text data were collected and respondents were not able to be identified by the study team, there was no ability to clarify or confirm themes or issues that were raised by pharmacists. Such difficulties could potentially have been overcome through the use of focus group discussion or interviews with pharmacists. Nevertheless, the written responses were generally detailed and clear, and the themes that © 2014 Royal Pharmaceutical Society

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emerged correlated well with those described by others. Williams and colleagues[25] in a recently published study that used focus groups to explore hospital pharmacists’ attitudes to reporting medication incidents identified a number of subthemes (e.g. workload pressures, management, blame culture, feedback, and interprofessional differences and relationships) that can be mapped to the themes that have emerged from our work. Their focus was solely on understanding positive and negative views of incident reporting programs, an important element in fostering a patient-safety culture, and the overlap with the themes presented in our study highlights the interaction among the themes and components that constitute patient-safety culture. Data used in this study were collected in 2010. Since that time, there have been a number of major pharmacy reforms within Australia. Several states have committed more resources to clinical pharmacy services and pharmacist numbers have been increased. It is possible that the safety climate within pharmacy departments in these jurisdictions has improved, especially considering that workforce issues were identified as a significant barrier to patient safety. All other identified barriers to and facilitators of a patientsafety culture are unlikely to have changed significantly since 2010. From the responses received, it appeared that many Australian hospital pharmacists and pharmacy departments have worked to improve the safety of care they provide, embracing the use of incident management systems and the associated concept of a system-based response to error rather than a person-focused response. The description of open and learning cultures in which incidents are freely reported, widely disseminated and promptly acted upon demonstrates that at least some Australian hospital pharmacy departments have developed quite mature and very positive patient-safety cultures. Contrasting views were also presented, indicating that some still believe there is a culture of blame that surrounds medication error and that work throughput is considered to be more important than quality and safety improvement activities. The contrasting attitudes among pharmacists, evident as barriers and facilitators of patient safety across many themes (Table 3), are noteworthy. This is reflective of different safety cultures, and knowledge of these characteristics can assist in developing strategies to target and improve organisational policies and practices that impede patient safety. A number of the themes discussed by pharmacists in this study have previously been described and explored in the literature.[25–27] Pharmacists providing comment for this study discussed issues relating to incident reporting systems. These systems must be acknowledged as one of the tools through which hospitals capture information about risks to patient safety. The attitudes of Australian hospital pharmacists in this study clearly demonstrated the need for these tools to be userInternational Journal of Pharmacy Practice 2014, ••, pp. ••–••

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friendly lest they become a barrier to improved practice and a culture of safety. Time-consuming or difficult-to-use systems were identified as strongly discouraging the reporting of clinical incidents, whereas easy-to-use systems were said to encourage reporting. These findings are in agreement with what has been reported by others, including Williams et al.[25] and Hartnell et al.,[26] who identified that reporter burden was a significant barrier to reporting medication incidents and that reducing this burden facilitates medication incident reporting. In addition to the usability of incident reporting systems, the impact of management’s response to error and incident reports on the attitudes of staff was clearly demonstrated by the respondents. Those who reported that they were provided feedback after making incident reports and that errors were responded to in a meaningful way associated this with a positive culture within the department and the likelihood that errors would be disclosed and acted upon. This finding is as anticipated and is in keeping with error and incident reporting theory,[14] but is an important reminder of the crucial role that managers play as leaders in supporting the safety and quality of care. Leroy and colleagues[27] have recently reported on the importance of nursing leaders and managers in fostering a culture whereby patient-safety incidents can be openly reported and staff adhere to safety protocols. This work demonstrated that nurse leaders who ‘walk their safety talk’ increase the perceived priority of patient safety within their team and the likelihood that team members would report incidents when they did occur.[27] The association between communication openness and submission of medical error reports by hospital pharmacists was similarly demonstrated by Patterson et al.[28] who reviewed the 2010 Hospital Survey on Patient Safety Culture conducted in the USA. In contrast to those open cultures described by some, it appears that a culture of blame exists within some hospital pharmacy settings. Respondents highlighted the need to focus on a just culture rather than a ‘no blame’ culture. The distinction being that in a just culture (as promoted by Reason[14] and other leaders in patient safety), there are clear boundaries established between what is acceptable and unacceptable behaviour. Some pharmacists reported that a ‘no blame’ culture may have contributed to a flippant response to error. The concepts of ‘no blame’ and a just culture both exist to create a sense of psychological safety where health care workers can report errors or incidents that have occurred without fear of being punished. It seems that, in some cases, pharmacists still feel that their errors will be used against them in a punitive fashion, regardless of the nature of the incident. Furthermore, pharmacists also reported concerns that submitting incident reports when medication errors were identified could affect relationships with other workers in their hospital. This is consistent with the views of hospital © 2014 Royal Pharmaceutical Society

Australian hospital pharmacists and patient safety

pharmacists in the UK where anxiety was associated with interprofessional tensions created by reporting medication incidents.[25] Interestingly, Australian hospital pharmacists described a discrepancy between the attitudes and beliefs of pharmacists and technicians. Pharmacy technicians were identified as a professional group who require further education, training and support regarding the concepts of a safety culture. Pharmacists reported that technicians lacked an understanding of both the importance of practising safely and of reporting and investigating errors in order to learn from them and prevent their recurrence. Other pharmacists reported that technicians may feel unable to raise concerns about potential safety issues or errors because of their perceived lack of power or authority within the pharmacy. Improving opportunities for training and creating an environment that acknowledges the role of technicians in patient safety and quality appear to be an important requisite for improving the overall safety culture of the hospital pharmacy. Importantly, the role of the technician in keeping the patient safe should be highlighted during orientation and reinforced regularly. The notion of the importance of fostering effective teams to deliver safer care has been reviewed by Baker and colleagues[29] who highlight the need to embed team training in professional development throughout the delivery of health care. Teamwork within the pharmacy department should be fostered to increase the ability of pharmacy technicians to speak up when they have safety concerns. Similar issues have been seen in other professions, including both medicine[30] and nursing,[27] as well as in multidisciplinary teams[31,32] where power gradients and hierarchy can limit the ability of team members to freely speak up for safety. Hospital pharmacy, as a profession, could learn from interventions that have been undertaken to limit power imbalance and promote speaking up for safety. Providing technicians with formal, structured language such as the ‘two-challenge’ rule[30] for questioning the actions of pharmacists[30,32] may help handle these potentially difficult situations and, ultimately, improve the safety of care delivered. Issues of workforce and workload were frequently discussed as barriers to safety. Responses related to these issues reported that work throughput was felt to be more important than the delivery of safe care. This finding reflects a tension between the requirement for safe practices, human capacity to perform and an organisation’s efforts to contain and allocate resources as described by Amalberti and colleagues[33] based on Jens Rasmussen’s theory of migration to boundaries.[34] It is concerning that pharmacists report feeling that hospital management has failed to invest in clinical pharmacy services or quality and safety initiatives. As the importance of patient safety and quality of care continues to be highlighted, the pharmacy profession must present a strong case for the value that it can provide. International Journal of Pharmacy Practice 2014, ••, pp. ••–••

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Conclusion

Funding

Australian hospital pharmacists have a range of attitudes to patient safety, error and incident reporting that reflect the existence of aspects of positive and negative patient-safety cultures in their work settings. There appears to be a perception that the culture towards patient safety among clinical hospital pharmacists is disconnected from that of the pharmacy and hospital management. Key facilitators of a positive patient-safety culture have included the use of incident reporting systems, dedicated medication safety staff and constructive responses to error from management. Strong leadership from within the pharmacy profession and hospital management is required to improve the patient-safety culture in some hospital pharmacy departments where a culture of blame remains.

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

Declarations Conflict of interest The Author(s) declare(s) that they have no conflicts of interest to disclose.

References 1. Department of Health. An Organisation with a Memory, a Report from an Expert Working Group on Learning from Adverse Events in the NHS. London: Department of Health, 2000. 2. Wilson RM et al. The Quality in Australian Health Care Study. MJA 1995; 163: 458–471. 3. Kohn LT et al. To Err Is Human: Building a Safer Health System. Washington, DC: Institute of Medicine, 2000. 4. Australian Council for Safety and Quality in Healthcare. Second National Report on Patient Safety: Improving Medication Safety. Canberra: Department of Health and Aging, 2002. 5. Society of Hospital Pharmacists of Australia. Organisational medication safety. Managing risk – how pharmacists help. Medicines in focus FACT SHEET. Collingwood, Victoria, Australia: Society of Hospital Pharmacists of Australia, 2013: 3. 6. Pedersen CA et al. ASHP national survey of pharmacy practice in hospital settings: monitoring and patient education – 2012. Am J Health Syst Pharm 2013; 70: 787–803.

© 2014 Royal Pharmaceutical Society

Acknowledgement This work was supported by the Roche Research Grant on Safety and Quality (grant number ROCHE0906) provided through the Society of Hospital Pharmacists of Australia.

Authors’ contributions DJL, TFC, RAF and DMA conceptualised and designed this study. Data collection was coordinated by DJL, TFC and RAF and analysis was undertaken by DJL, RAG and RW. The analysis was reviewed by all Authors. DJL drafted the manuscript that was subsequently revised and approved by all Authors with all Authors making contribution to the final manuscript. All Authors state that they had complete access to the study data that support the publication.

7. Classen DC, Metzger J. Improving medication safety: the measurement conundrum and where to start. Int J Qual Health Care 2003; 15(Suppl. 1): i41–i47. 8. Pronovost PJ et al. Tracking progress in patient safety. JAMA 2006; 296: 696– 699. 9. Pham C et al. What to do with healthcare Incident Reporting Systems. J Public Health Res 2013; 2(e27): 154– 159. 10. Kilbridge PM, Classen DC. Automated surveillance for adverse events in hospitalized patients: back to the future. Qual Saf Health Care 2006; 15: 148– 149. 11. Rozich JD et al. Adverse drug event trigger tool: a practical methodology for measuring medication related harm. Qual Saf Health Care 2003; 12: 194–200. 12. Mattsson TO et al. Assessment of the global trigger tool to measure, monitor and evaluate patient safety in cancer patients: reliability concerns are raised. BMJ Qual Saf 2013; 22: 571–579. 13. Olsen S et al. Hospital staff should use more than one method to detect adverse events and potential adverse

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