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LIKELIHOOD
OF REPORTING PATIENT SAFETY INCIDENTS : THE CASE OF COMMUNITY PHARMACY
Ashcroft
DM, Morecroft C, Parker D†, Noyce P
School of Pharmacy and Pharmaceutical Sciences, †School of
Psychological Sciences, University of Manchester, M13 9PL
darren.ashcroft@manchester.ac.uk
Introduction
In 2004, the National Patient Safety Agency (NPSA) launched the National
Reporting and Learning System, designed to co-ordinate the reporting of patient
safety incidents nationally and improve the ability of the health service to
learn from the analysis of these events. More recently, requirements for
reporting medication-related patient safety incidents have been included in the
proposals for the new national pharmacy contract. Despite this, very little is
known about levels of community pharmacy staff engagement with incident
reporting schemes generally and the NPSA scheme specifically. The aim of this
study was to explore the likelihood of community pharmacists and support staff
reporting incidents that occur in community pharmacies.
Method
Questionnaire survey to community pharmacists and support staff, containing
nine incident scenarios relating to incidents involving written protocols. In
the scenarios, two factors were orthogonally manipulated: the outcome for the
patient was reported as either good, bad or poor, and the behaviour of the
pharmacist was described as either complying with a protocol, not being aware of
a protocol (error), or violating a protocol. Respondents were asked to imagine
that they had witnessed the situation described and rate whether they would
report the incident (1) locally within the pharmacy and (2) nationally to the
NPSA. Responses were recorded on a five-point scale with endpoints labelled
"very unlikely" (1) to "very likely" (5). Results were
analysed using repeated measures analysis of variance (ANOVA) in SPSS
v11.5.
Results
In all, 275 questionnaires were returned (79% response rate) from 223
community pharmacists and 52 members of support staff. As might be expected,
there were linear trends showing that when the behaviour led to a good outcome
it is far less likely to be reported than when it led to a poor or bad outcome
and these trends applied across all three behaviour types. However, even when
the scenarios depicted poor or bad outcomes and there had been violations or
errors, ratings of the likelihood of reporting were below the mid-point of the
scale indicating that, overall, the likelihood of reporting the incident was
low. There were significant main effects for both patient outcome (F(2,520) =
18.19, p<0.001) and behaviour type (F(2,520) = 93.98, p<0.001), indicating
that pharmacists and support staff would take into account both the outcome of
the behaviour and whether or not it follows a protocol when considering to
report an incident within the pharmacy. Likewise, both pharmacists and support
staff considered patient outcome (F(2,524) = 12.59, p<0.001) and behaviour
type (F(2,524) = 34.82, p<0.001) when considering to report to the NPSA.
Across both outcomes, judgements on whether to report an incident were most
affected by the behaviour of the pharmacist in relation to protocols than the
resulting outcome for the patient.
Discussion
In considering whether to report an incident, community pharmacists did take
into account both the outcome of the behaviour and whether or not it follows a
protocol. Nonetheless, the results show that overall community pharmacists and
support staff would be unlikely to report adverse incidents if they witnessed
them occurring in a community pharmacy, raising concerns about the
comprehensiveness of existing reporting schemes and the ability to learn from
adverse events.
References
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Reason JT, Parker D, Lawton R. Organisational controls
and safety: the varieties of rule-related behaviour. J Organisat Occup
Psychol 1998;71:289-304
Presented at the HSRPP Conference 2005, Reading
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