Managing Risk, Trust, and Medication Error in Hospital Pharmacies

In healthcare there is growing recognition of the need to collect and analyse data on adverse incidents in order to facilitate learning and improve patient safety. Several countries have introduced national or system-wide... [ view full abstract ]

In healthcare there is growing recognition of the need to collect and analyse data on adverse incidents in order to facilitate learning and improve patient safety. Several countries have introduced national or system-wide reporting systems to monitor and analyse incident data but due to barriers in reporting like a lack of trust, reporting systems do not provide a reliable index of the rate of adverse incidents.

Medication incident reports involve incidents which actually caused harm or had the potential to cause harm due to an error in the process of prescribing, dispensing, preparing, administering, monitoring or providing medicines. The most frequently reported types of medication incidents involve the wrong dose, omitted or delayed medicines, or the wrong medicines. Medication error has been studied extensively in hospital nurses but little is known about the role of hospital pharmacists in reviewing medication orders or pharmacists’ potential for error.

A deficient safety culture has been associated with a higher error rate in organisations, and identified as a causal factor in industrial disasters and adverse events in healthcare. Reason (1997) proposed that an effective safety culture could be socially engineered by developing three subcomponents: a reporting culture, a just culture, and a learning culture. He argued that these subcomponents are based on an underlying element of trust. While evidence to support the role of trust in safety culture has started to emerge, Reason’s model has yet to be validated fully.

There are many barriers to incident reporting in healthcare. Inhibitive reporting cultures and lack of adequate systems have been identified as important barriers to reporting but most studies are based on traditional paper-based reporting systems and many healthcare organisations have now adopted electronic reporting systems. While researchers have started to investigate barriers to electronic adverse incident reporting in hospitals, almost no studies have focussed on medication error and pharmacy staff.

This poster will report the findings from interviews and a questionnaire survey in order to:
i) Explore factors associated with medication error in hospital pharmacies
ii) Investigate attitudes, risk perceptions, trust beliefs, and trust intentions with respect to reporting medication errors so as to test Reason’s model of safety culture
iii) Identifies socio-technical barriers to reporting medication errors using electronic reporting systems.