Exploring the human factors of medication errors in community pharmacy: a mixed methods study

IntroductionThe objective of this study was to use a prospective error analysis method to examine the process of dispensing medication in community pharmacy settings and identify remedial solutions to avoid potential errors, categorising them as strong, intermediate, or weak based on an established patient safety action hierarchy tool.MethodFocus group discussions and non-participant observations were undertaken to develop a Hierarchical Task Analysis (HTA), and subsequent focus group discussions applied the Systematic Human Error Reduction and Prediction Approach (SHERPA) focusing on the task of dispensing medication in community pharmacies. Remedial measures identified through the SHERPA analysis were then categorised as strong, intermediate, or weak based on the Veteran Affairs National Centre for Patient Safety action hierarchy. Non-participant observations were conducted at 3 pharmacies, totalling 12 hours, based in England. Additionally, 7 community pharmacists, with experience ranging from 8 to 38 years, participated in a total of 4 focus groups, each lasting between 57 to 85 minutes, with one focus group discussing the HTA and three applying SHERPA. A HTA was produced consisting of 10 sub-tasks, with further levels of sub-tasks within each of them.ResultsOverall, 88 potential errors were identified, with a total of 35 remedial solutions proposed to avoid these errors in practice. Sixteen (46%) of these remedial measures were categorised as weak, 14 (40%) as intermediate and 5 (14%) as strong according to the Veteran Affairs National Centre for Patient Safety action hierarchy. Sub-tasks with the most potential errors were identified, which included ‘producing medication labels’ and ‘final checking of medicines’. The most common type of error determined from the SHERPA analysis related to omitting a check during the dispensing process which accounted for 19 potential errors.DiscussionThis work applies both HTA and SHERPA for the first time to the task of dispensing medication in community pharmacies, detailing the complexity of the task and highlighting potential errors and remedial measures specific to this task. Future research should examine the effectiveness of the proposed remedial solutions to improve patient safety.

To review and evaluate research on pharmaceutical services in community and ambulatory care pharmacy settings, specifically study designs and patient outcome measures, and to provide recommendations to improve future research on pharmaceutical services in community and ambulatory care pharmacy settings. English-language articles were identified by searching MEDLINE (1966-December 1998) and International Pharmaceutical Abstracts (1970-December 1998), using a combination of search terms: pharmacist services, pharmacist interventions, community pharmacy, ambulatory care, primary care, and patient outcomes. Relevant studies were selected based on article abstracts. From each relevant study, we extracted the study objectives, sample size, study period, study design, major tasks performed by pharmacists, and economic, clinical, and humanistic outcomes (ECHO). Results were tabulated separately for research on community pharmacy and ambulatory care pharmacy settings. We identified 95 relevant studies. Of these, 21 studies were conducted in community pharmacy settings and 74 in ambulatory care settings. Ten community pharmacy studies used prospective, single group, pretest/posttest, or posttest only designs; seven used prospective two or more group comparison designs; and four used randomized, controlled designs. Nine studies on community pharmacies measured clinical outcomes, two measured humanistic outcomes, and five measured economic outcomes. Four studies measured both clinical and humanistic outcomes and one measured humanistic and economic outcomes. No study measured all three ECHO variables. Twenty-three studies in ambulatory care settings used prospective or retrospective, single group, pretest/posttest or posttest only designs; 21 used prospective or retrospective two-or-more group comparison designs; and 30 used randomized, controlled designs. Thirty-six measured clinical outcomes, five measured humanistic outcomes, and 15 measured economic outcomes. Fifteen studies measured clinical and economic outcomes and three measured clinical and humanistic outcomes. Only 21 of 95 selected studies were conducted in community pharmacy settings and measured the impact of pharmaceutical services on patient outcomes. Few studies employed adequate research designs to control threats to internal and external validity. In order to obtain a comprehensive and accurate picture of the impact of pharmaceutical services on patient outcomes, an attempt must be made to measure all three ECHO variables while employing adequate research design.

Medication errors in community pharmacies: The need for commitment, transparency, and research.

Clinical decision support software (CDSS) has been increasingly implemented to assist improved prescribing practice. Reviews and studies report generally positive results regarding prescribing changes and, to a lesser extent, patient outcomes. Little information is available, however, concerning the use of CDSS in community pharmacy practice. Given the apparent paucity of publications examining this topic, we conducted a review to determine whether CDSS in community pharmacy practice can improve medication use and patient outcomes. A literature search of articles on CDSS relevant to community pharmacy and published between 1 January 2005 and 21 October 2013 was undertaken. Articles were included if the healthcare setting was community pharmacy and the article indicated that pharmacy use of CDSS was part of the study intervention. Eight studies were found which assessed counselling, selected drug interactions, inappropriate prescribing and under-prescribing. One study was halted due to insufficient data collection. Six studies showed statistically significant improvements in the measured outcomes: increased patient counselling, 31% reduced frequency of drug-drug interactions (DDIs), reduced frequency of inappropriate medications in the elderly (2·2-1·8% patients) and in pregnant women (5·5-2·9% patients), and increased pharmacists' interventions for under-prescribed low-dose aspirin (1·74 vs. 0·91 per 100 patients with type 2 diabetes) and over-prescribed high-dose proton-pump inhibitors (PPIs) (1·67 vs. 0·17 interventions per 100 high-dose PPI prescriptions). Most studies showed improved prescribing practice, via direct communication between pharmacists and doctors or indirectly via patient education. Factors limiting the impact of improved prescribing included alert fatigue and clinical inertia. No study investigated patient outcomes and little investigation had been undertaken on how CDSS could be best implemented. Few studies have been undertaken in community pharmacy practice, and based on the positive findings reported, further research should be directed in this area, including investigation of patient outcomes.

Student observations of medication error reporting practices in community pharmacy settings.

Barriers and facilitators to recovering from e-prescribing errors in community pharmacies

Mind the gap: Examining work-as-imagined and work-as-done when dispensing medication in the community pharmacy setting

Objectives:To assess the incidence, types, the causes of as well as the factorsassociated with dispensing errors in community pharmacies in Lebanon.Methods:An observational cross-sectional study was conducted in 286 pharmacieslocated all over Lebanon. Data were collected by senior pharmacy studentsduring their experiential learning placement. Collected data includedinformation on the types of dispensing errors, the underlying causes oferrors, handling approaches, and used strategies for dispensing errorprevention. Data were analyzed using multiple logistic regression todetermine factors that were associated with dispensing errors.Results:In the twelve thousand eight hundred sixty dispensed medications, there were376 dispensing errors, yielding an error rate of 2.92%. Of theseerrors, 67.1% (252) corresponded to dispensing near-miss errors. Themost common types of dispensing errors were giving incomplete/incorrect useinstructions (40.9% (154)), followed by the omission of warning(s)(23.6% (89)). Work overloads/time pressures, illegible handwriting,distractions/interruptions, and similar drug naming/packaging were reportedas the underlying causes in 55% (206), 23.13% (87), 15.15% (57), and 7% (26) of the errors respectively. Besides, highprescription turnover volume, having one pharmacist working at a time, andextended working hours, were found to be independent factors that weresignificantly associated with dispensing errors occurrence(p<0.05).Conclusions:This study sheds light on the need to establish national strategies forpreventing dispensing errors in community pharmacies to maintain drugtherapy safety, considering identified underlying causes and associatedfactors.

BackgroundSharing tasks with lower cadre workers may help ease the burden of work on the constrained nursing workforce in low- and middle-income countries but the quality and safety issues associated with shifting tasks are rarely critically evaluated. This research explored this gap using a Human Factors and Ergonomics (HFE) method as a novel approach to address this gap and inform task sharing policies in neonatal care settings in Kenya.MethodsWe used Hierarchical Task Analysis (HTA) and the Systematic Human Error Reduction and Prediction Approach (SHERPA) to analyse and identify the nature and significance of potential errors of nasogastric tube (NGT) feeding in a neonatal setting and to gain a preliminary understanding of informal task sharing.ResultsA total of 47 end tasks were identified from the HTA. Sharing, supervision and risk levels of these tasks reported by subject matter experts (SMEs) varied broadly. More than half of the tasks (58.3%) were shared with mothers, of these, 31.7% (13/41) and 68.3% were assigned a medium and low level of risk by the majority (≥4) of SMEs respectively. Few tasks were reported as ‘often missed’ by the majority of SMEs. SHERPA analysis suggested omission was the commonest type of error, however, due to the low risk nature, omission would potentially result in minor consequences. Training and provision of checklists for NGT feeding were the key approaches for remedying most errors. By extension these strategies could support safer task shifting.ConclusionInclusion of mothers and casual workers in care provided to sick infants is reported by SMEs in the Kenyan neonatal settings. Ergonomics methods proved useful in working with Kenyan SMEs to identify possible errors and the training and supervision needs for safer task-sharing.

Introduction: Because Taiwan is surrounded by sea, its international trade depends on air and sea transportation. Sea transportation is the most popular way to transport chemical goods. The workers who participate in this process include sailors, operators and ship members. This study aims to detect the potential human factors and calculate human reliability within this process. Method: The Hierarchical Task Analysis (HTA) was used to decompose the whole work into units and to analyze the processes; Systematic Human Error Reduction and Prediction Approach (SHERPA) was used to detect the possible human factors in this process. The questionnaire also was used to investigate the workers’ experience about program design and the hardware practicability. A group of 40 workers participated. Result: According to HTA, the whole work decomposed into 7 parts: arrivals, loading preparation, pre-loading, loading, pro-loading, leaving preparation, and departures. SHERPA found the most popular error types were action error (49%) and check error (44%). And the questionnaire analysis of the workers’ experience about the program design and hardware practicability showed that the workers’ knowledge and attitude had a negative relationship. Discussion: The results of HTA and SHERPA indicate that the potential human factors play a huge proportion in this process. The suggestions are that program design could be improved and the workers need reeducation.

This systematic aimed to understand the global status using the results of survey studies based on the Community Pharmacy Survey on Patient Safety Culture and set the directions of development in terms of the patient safety culture of community pharmacies. Electronic searches were performed in EMBASE, MEDLINE, PubMed, and CINAHL databases by using the words "patient safety," "culture," and "community pharmacy" with synonyms or associated words in the original English language research articles published between January 1, 2012, and March 2, 2023. This systematic review was conducted based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Eleven surveys from 10 countries were selected. Five studies were conducted on pharmacists, whereas 6 studies were carried out on all pharmacy staff members such as pharmacists, technicians, clerks, and pharmacy students on apprenticeship. There was a considerable variation in the positive response rates across the dimensions of all the surveys. The highest positive response score was demonstrated for "teamwork" and "patient counseling," whereas the "staffing, work pressure, and pace" dimension was essential for improving patient safety culture in community pharmacy settings. For overall rating of the pharmacy on patient safety, 84.8% of pharmacy staff members gave good, very good, or excellent as their responses. Despite the differences among studies, findings of this study are expected to be used as valuable evidence to develop patient safety improvement strategies after reflecting each country's health care setting or community pharmacy practice. Furthermore, the results would offer meaningful assistance to achieve the goals of global campaigns such as the World Health Organization Patient Safety Challenge.

Objective The community pharmacy is one setting that plays a crucial role in patient safety. To develop tailored patient safety improvement programs in this setting, it is essential to know the perspectives of the pharmacies’ staffs on patient safety. Thus, in this study, we assessed patient-safety culture in the community pharmacy setting in Saudi Arabia. Methods Between January and August of 2019, we conducted a cross-sectional study among staff working in the community pharmacies in Saudi Arabia. Data on patient safety culture were collected using the Pharmacy Survey on Patient Safety Culture (PSOPSC). Analyses were performed with descriptive statistics (frequency/percentages), Fisher’s Exact test, Chi-square analysis, and multivariable ordinal logistic regression with proportional odds model analysis. Results PSOPSC data from 805 community pharmacies in Saudi Arabia were received (response rate: 78%). The overall average positive response rate for the 11 dimensions of the PSOPSC survey was 60.2%, with a range from 34.8% in the dimension of Staffing, Work Pressure, and Pace to 76.4% in the dimension of Teamwork. Most participants responded positively, as in total, 504 (62.6%) of the participants rated their pharmacy as ‘excellent’ or ‘very good’ on patient safety. Gender and work experience in a pharmacy were important predictors of the overall patient safety grade. Conclusions The study revealed that all dimensions are scope for further improvement, and critical consideration ought to be given to the areas of weakness, for the most part in the dimension of Staffing, Work Pressure, and Pace.

Incident reporting offers insight into a variety of intricate processes in healthcare. However, it has been found that medication incidents are under reported in the community pharmacy setting. The Community Pharmacy Incident Reporting (CPhIR) program was created by the Institute for Safe Medication Practices Canada specifically for incident reporting in the community pharmacy setting in Canada. The initial development of key elements for CPhIR included several focus-group teleconferences with pharmacists from Ontario and Nova Scotia. Throughout the development and release of the CPhIR pilot, feedback from pharmacists and pharmacy technicians was constantly incorporated into the reporting program. After several rounds of iterative feedback, testing and consultation with community pharmacy practitioners, a final version of the CPhIR program, together with self-directed training materials, is now ready to launch. The CPhIR program provides users with a one-stop platform to report and record medication incidents, export data for customized analysis and view comparisons of individual and aggregate data. These unique functions allow for a detailed analysis of underlying contributing factors in medication incidents. A communication piece for pharmacies to share their experiences is in the process of development. To ensure the success of the CPhIR program, a patient safety culture must be established. By gaining a deeper understanding of possible causes of medication incidents, community pharmacies can implement system-based strategies for quality improvement and to prevent potential errors from occurring again in the future. This article highlights key features of the CPhIR program that will assist community pharmacies to improve their drug distribution system and, ultimately, enhance patient safety.

Patient safety is the primary concern in healthcare service delivery. One of the efforts to achieve patient safety is to prevent medication errors. Pharmacists in community pharmacies, who have a broader reach with patients, can help prevent medication errors by understanding the types of errors that are at risk of occurring during the service process. The aim of this study was to summarize the types of medication errors most commonly found in community pharmacies. This study is a scoping review using search methods from the PubMed, SpringerLink, and Cochrane Library databases, and it covers studies on a global scale. The search resulted in 15 articles that met the inclusion criteria. The quality of these articles was assessed using the Critical Appraisal Skills Program. The review of these articles found that dispensing errors occurred more frequently than prescription errors, administration errors, and monitoring errors. Several subtypes of each medication error type were identified, but they were categorized based on the stages of the pharmaceutical service process in accordance with the practice in community pharmacies.

ObjectiveTo develop a hierarchical task listing of steps required to perform successful Functional Endoscopic Sinus Surgery (FESS). To complete a technical and human factor analysis of tasks resulting in the identification of errors, frequency of occurrence, severity, and reduction through remediation.MethodsA triangulation of methods was used in order to derive the steps required to complete a FESS: 1) a literature review was carried out of published descriptions of FESS techniques; 2) observations of three FESS; 3) interviews with surgeons on FESS techniques. Data sets were combined to develop a task analysis of a correct approach to conducting FESS. A review by 12 surgeons, and observation of 25 FESS resulted in refinement of the task analysis. With input from five consultant surgeons and one consultant anesthetist, a Systematic Human Error Reduction and Prediction Approach (SHERPA) was used to identify the risks and mitigating steps in FESS.ResultsTen tasks and 49 subtasks required for a correct approach to completing FESS were identified based on literature review and expert consensus. A risk score for each subtask was calculated from a suitable risk matrix. Risk reduction methods at each subtask were detailed. High‐scoring subtasks were evaluated and varying strategies examined to reduce the likelihood and mitigate the impact of error. The study demonstrates the usefulness of the HTA and SHERPA approach in standardization and optimization of clinical practice in order to improve patient safety.ConclusionHierarchical Task Analysis and SHERPA are valuable tools to deconstruct expert performance and to highlight potential errors in FESS. The HTA and SHERPA approach to surgical procedures are useful learning and assessment tools for novice surgeons. The information derived offers the opportunity to improve surgical training and enhance patient safety by identifying high‐risk steps in the procedure, and how risk can be mitigated.Level of Evidence2c Outcomes Research