Research in Social and Administrative Pharmacy 9 (2013) 8089

Original Research

Understanding the attitudes of hospital pharmacists to reporting medication incidents: A qualitative study
Steven D. Williams, M.Phil.a,b,*, Denham L. Phipps, Ph.D.b, Darren M. Ashcroft, Ph.D.a,b
Department of Pharmacy, University Hospital of South Manchester NHS Foundation Trust, Southmoor Road, Wythenshawe, Manchester M23 9LT, UK b Centre for Pharmacoepidemiology and Drug Safety Research, School of Pharmacy and Pharmaceutical Sciences, Manchester Academic Health Sciences Centre (MASHC), University of Manchester, Manchester, UK
a

Abstract Background: The attitudes of doctors, nurses, and midwives to reporting errors in health care have been extensively studied, but there is very limited literature considering pharmacists attitudes to medication error reporting schemes, in particular in hospitals. Objectives: To explore and understand the attitudes of hospital pharmacists to reporting medication incidents. Methods: Focus groups were conducted with a total of 17 hospital pharmacists from 4 purposively sampled hospitals in the North West of England. The recordings of the focus groups were transcribed verbatim and subject to thematic analysis using a framework analysis approach. Results: Pharmacists agreed that the high prevalence of medication errors, especially prescribing errors of omission, has led to an acceptance of not using hospital reporting systems. There were dierent personal thresholds for reporting medication errors but pharmacists agreed that the severity of any patient harm was the primary reporting driver. Hospital pharmacists had specic anxieties about the eects of reporting on interprofessional working relationships with doctors and nurses, but felt more condent to report if they had previously witnessed positive feedback and system change following an error. Existing reporting forms were considered too cumbersome and time consuming to complete, as pharmacists felt the need to nd and record every possible detail. Conclusions: Hospital pharmacists understood the importance of reporting medication incidents, but because of the high number of errors they encounter do not report them as often as may be expected. The decision to report was a complex process that depended on the severity of patient harm, anxieties about harming interprofessional relationships, prior experience of the outcomes from reporting, and the perceived eort required to use reporting forms. 2013 Elsevier Inc. All rights reserved.
Keywords: Medication incidents; Hospital pharmacists; Error reporting; Adverse events; Patient safety

* Corresponding author. Department of Pharmacy, University Hospital of South Manchester NHS Foundation Trust, Southmoor Road, Wythenshawe, Manchester M23 9LT, UK. Tel.: 44 (0)161 291 2113. E-mail address: steve.williams@uhsm.nhs.uk (S.D. Williams). 1551-7411/$ - see front matter 2013 Elsevier Inc. All rights reserved. doi:10.1016/j.sapharm.2012.02.002

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Introduction The interest in health care adverse events (errors/incidents) has increased substantially following the publication of the Institute of Medicines (IOM) To err is human report in the United States,1 an Organization with a Memory in the UK,2 and similar reports in other developed countries.3,4 Although the scale of the problem appears large, with the IOM reporting that more than 1 million preventable adverse events occur each year in the United States, the reality is that the problem is probably even larger, with estimates of under reporting of events ranging from 50% to 96% annually.5 The attitudes of doctors, nurses, and midwives to reporting errors in health care have been extensively studied in general medical/surgical care6,7 and across a wide range of specialties including obstetrics,8 paediatrics,9 intensive care,10 and in the nursing home setting.11 With the possible exception of obstetricians and midwives,12,13 the attitudes of health professionals to reporting errors appear to be driven by negative attitudes about why not report (barriers), as opposed to positive attitudes about why they should report (benets). The barriers have consistently been found to be broadly 4-fold: knowledge of what and when to report, the eort required to complete a report, the personal fears about the consequences of reporting, and the perceived lack of feedback or positive change following an error report.14 There is very limited literature considering pharmacists attitudes. Clearly, the training, role, and function of hospital pharmacists in the medicine use process are very dierent to medical and nursing colleagues, which may mean that their attitudes to errors and reporting behavior is dierent. From the published literature, it would appear that apprehension and suspicion about reporting schemes because of the fears of the consequences for the pharmacist involved in the error, appear to be the overriding attitude of pharmacists to reporting medication errors.15-17 Semistructured interviews with 36 pharmacy sta from a U.S. teaching hospital revealed that pharmacy sta made a conscious decision whether to formally report an incident via the hospital reporting system or document the incident as a pharmacy intervention, as it aected their annual appraisal.15 Sta were formally rewarded at appraisal for interventions made, but formally recorded incidents involving themselves were used to compare sta with their peers. The department promoted a nonpunitive

culture but sta perception of that varied and pharmacists rarely led formal incident forms involving themselves or other pharmacy colleagues. A U.S. focus group study considered barriers to reporting as part of a broader evaluation of a regional medication error reporting system, where the 14 health professionals were involved in either data collection or utilization.16 Inadequate stang was identied as a major barrier to reporting because of the time-consuming nature of conrming medication errors and the collection of relevant details. Suggestions for improving reporting rates included dedicated medication safety managers or increasing the use of pharmacy technical support sta. A questionnaire study investigating the likelihood of reporting adverse events with 275 UK community pharmacy sta revealed a lack of understanding about reporting schemes and a deep resentment and mistrust about their need, due to fears of repercussions for the pharmacist involved.17 Nine dierent scenarios involving dispensing or supply of a medicine, and whether the behavior of the community pharmacist involved compliance (in line with protocol), violation (deliberate deviation from protocol), or error (not being aware of a protocol) were presented but participants were found to be unlikely or very unlikely to report any of the events to a local, or the national, reporting scheme. More recently, Boyle at al18 considered the attitudes to medication incident reporting in a Webbased survey involving 72 community pharmacy sta in Canada. Pharmacists, pharmacy managers, and pharmacy technicians were somewhat ambivalent about the impact on day-to-day operations, the ease of completion of current reporting systems, and the personal support given to individuals involved in errors. The 2 most common complaints about reporting systems were the lack of a formal process and feedback after an error had occurred. The ability of a system to encourage more open learning and ultimately reduce medication incidents, in addition to the need for appropriate training and technical support for the system, were identied as some of the most desirable features of any new incident reporting system. Similarly, the sharing of learning from errors, and ensuring anonymity for sta, were rated most highly as factors that would likely increase reporting and learning. The attitudes of UK hospital pharmacists to reporting medication errors are currently unknown, yet in the recent EQUIP study the prevalence of prescribing errors alone in UK hospitals was

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found to be almost 9%.19 The observed dierence between the detection and reporting of medication errors in the 19 hospitals studied was stark with less than 0.2% of the detected prescribing errors being voluntarily reported via the hospitals incident reporting system (P. Lewis, EQUIP researcher, personal communication, 10th August 2011). Similarly, a direct observation of medication administration in 36 U.S. hospitals revealed an 11.7% error rate compared with just 0.04% for errors detected through the incident reporting scheme.20 If the benet of reporting errors is for organizations to learn, and change practices/systems to improve medication safety, then the literature suggests that individual hospitals do not have all the necessary medication incident data to accomplish this. This may therefore be inhibiting the ability of hospitals to learn from medication errors and more importantly to take steps to protect future patients from repetitive medication harms. A better understanding of why hospital pharmacists do not appear to report medication errors that occur is therefore warranted, particularly as there is also emerging evidence that better voluntary incident reporting per se is associated with a more positive patient safety culture in hospitals.21 Methods Ethical approval for this study was granted from the South Manchester NHS Research Ethics Committee to invite hospital pharmacists from 4 hospitals, in the North West of England, to take part in the study. Purposive sampling was used to invite dierent sized and types of hospitals, whose pharmacy sta had scored them positively, neutrally, and negatively in a previous survey exploring the attitudes of pharmacy sta to patient safety climate.22 Lead clinical pharmacy managers in the 4 hospitals were asked to invite, by e-mail, all pharmacists in their department with the aim of recruiting 1 pharmacist from each pay band (representing seniority and experience), up to a maximum of 7 pharmacists. An interview schedule was designed to help establish local hospital reporting and learning systems, and participants positive and negative attitudes to reporting medication errors. The schedule was based on the extensive literature studying the attitudes and barriers to reporting incidents6,7,23 (Appendix). The focus groups were conducted between May and June 2008 and typically lasted between 40 and

60 minutes. The digital recordings of the focus groups were transcribed verbatim and then read in detail by the researchers on multiple occasions. The data were subject to thematic analysis by the lead researcher (SDW) using a framework analysis approach.24 Framework analysis allows some initial assumptions based on the literature to be used but is a systematic process using 5 key stages to analyze and sort data according to emergent key themes: familiarization, identifying a thematic framework, indexing, charting, mapping, and interpretation. The other members of the research team (DMA, DP) additionally analyzed the data independently to elucidate the nal emergent themes from the focus groups. Results The characteristics of the pharmacists recruited from the 4 hospitals who took part in the focus groups are shown in Table 1. The size of the focus groups varied between 2 and 6 pharmacists, and the overall gender mix was 12 females to 5 males, which is in line with UK-hospital pharmacy workforce data.25 Three out of the 4 hospitals used paper incident reporting forms and 1 had a fully electronic incident reporting system. The 3 hospitals with paper forms had 2 dierent types of error reporting forms, 1 which was hospital wide for reporting any type of incident, including medication errors, and another internal form that was exclusively for pharmacy sta to report either dispensing errors or other medication errors only. In general terms, pharmacists from 2 of the pharmacy departments appeared very comfortable reporting medication errors and were very positive about the benets of reporting, because of a perception of strong pharmacy leadership and a history of constructive changes following reported medication errors. One of those hospitals had a medication safety pharmacist whose role was to escalate the internal pharmacy reporting forms, via the hospital wide system, on behalf of the reporting pharmacist when the incident appeared to be a serious or a repetitive system type error. The remaining pharmacy departments appeared to have an overriding anxiety about the eect of reporting on their professional relationships with other health professionals, and 1 appeared to be adversely aected by a recent internal investigation regarding a medication error. Framework analysis of the 4 focus groups revealed 7 main themes, with associated subthemes as presented in Table 2.

Williams et al. / Research in Social and Administrative Pharmacy 9 (2013) 8089 Table 1 Characteristics of the focus groups Focus group 1 Type of hospital Number of acute beds Gender of participants Hospital pharmacy experience of participants General 350 5 female F1 F2 F3 F4 F5 23 yr 18 yr 3 yr 1 yr 13 yr Focus group 2 University teaching 900 4 female 2 male F1 4 yr F2 5 yr F3 3 yr F4 6 yr M1 4 yr M2 20 yr Paper hospital wide incident form plus pharmacy-specic form for recording medication errors identied in pediatrics only Focus group 3 General 750 1 female 3 male F1 6 yr M1 4 yr M2 11 yr M3 22 yr Focus group 4

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University teaching 1100 2 female F1 1 yr F2 2 yr

Medication error reporting system in place at study hospitals

Paper hospital wide incident form plus pharmacy-specic dispensing error form if error detected before leaving department

Paper incident form specically for medication errors (escalated to hospital wide incident form by dedicated pharmacist as necessary)

Electronic hospital wide incident form

Working environment An important theme that emerged was the NHS hospital environment in which pharmacists operate, where medication errors are considered to be endemic and was accepted as part of the job to identify and report medication errors. However, given that workload pressures were so intense all participants felt that medication errors do not get reported as often as they should, even if they wanted to report them all.
If we reported every time something was missed o a patients drug history wed probably make a report about every patient.well, youd have no time to do anything else. (Focus group 4: large teaching hospital with electronic reporting systemdFemale with 1 years pharmacy experience.)

.think there is certainly a perception and probably not an unwarranted one, that the way medical sta are dealt with, treated, approached, when it comes to when an error has happened is a lot dierent. (Focus group 3: large general hospital with paper reporting systemdMale with 4 years pharmacy experience.)

Pharmacists appeared to feel more comfortable reporting where there was a history of departmental and/or hospital belief in the benets of reporting but did not appear to welcome managerial requests to just report more to justify hospital pharmacists worth. There was also a belief that speaking directly to the health professionals involved in any errors could be more successful, and less stressful, than formally reporting the incident or writing in clinical notes.
There are better ways of dealing with things that still achieve the same end. Like yesterday. they couldve lled an incident form in about that, but instead of which weve dealt with it, weve sorted it, the consultant is informed, the policys going to be reviewed, the patients, you know, had the treatment that they need, even though its not in the guidelines, and. theres none of the witchhunt, kind of nobodys cross or upset about it and everybodys like Oh, thanks a lot, were gonna sort this out now. And that means that the problem is resolved but we didnt ll an incident form in even though we couldve. (Focus group 1: small general hospital with paper reporting systemd Female with 18 years pharmacy experience.)

It was conceded that being busy was not a good enough excuse not to report errors, but that there was maybe a general apathy to reporting among pharmacists because of the scale of the problem. The concept of a blame culture appeared to exist with additional concerns about the way dierent health professionals were treated following an incident.
People still think, its a form, my God, someones gonna come down from up on high and shoot me. (Focus group 2: large teaching hospital with paper reporting systemdMale with 4 years pharmacy experience.)

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Williams et al. / Research in Social and Administrative Pharmacy 9 (2013) 8089 If youre working in a fairly discrete clinical team, pharmacists have, I think, historically had diculty nding a role within a team, nding acceptance of people accepting pharmacists roles, and I think sometimes you may be a little cautious about wanting to jeopardize that, particularly if its a team that you work closely with. (Focus group 3: large general hospital with paper reporting systemd Male with 4 years pharmacy experience.)

Table 2 Thematic framework Theme Environment Subtheme Management Job role Blame culture Interprofessional dierences Workload pressures Direct communication Personal Professional relationships Seniority Severity Drug System error Justication Repetition Personal judgment Omission errors (medicines reconciliation) Time Data set Paper vs electronic Anonymity Form confusion Change in practice In action Improve safety/care Reporter condence Positive feedback Preventing recurrence Identify safety problem Form simplicity Targeted reporting Anonymity Technology Feedback Drug specic

Anxieties

Incident

There was also agreement among all participants that junior pharmacists would have the greatest concerns reporting more senior health professionals involved in medication errors. Pharmacists clearly understood the tensions that could be created by medication error reports and often they had adopted strategies to try to reduce this conict, such as educating prescribers about their actions.
If youve got a new house ocer, and they make a mistake and its because of their inexperience, youre probably more likely to sit down and say, Youve put this medication on the wrong person, what can we do about it? And then if they do it again you ll out an incident report, but possibly on the rst one youre less likely to because youre building a professional relationship and also you have an inexperienced colleague who you can educate. (Focus group 2: large teaching hospital with paper reporting systemdFemale with 6 years pharmacy experience.)

System

Learning

Improvements

However, the alternative was for pharmacists to choose not to report medication errors because of their anxieties, especially when senior medical and nursing sta had openly tried to discourage pharmacists from reporting.
I made. an unfortunate error of suggesting to a senior doctor that he ll out an incident report on something that had happened on a ward and had my head bitten o. (Focus group 2: large teaching hospital with paper reporting systemdFemale with 6 years pharmacy experience.)

Anxieties The vast majority of hospital pharmacists worried about the eects of reporting medication errors on interprofessional working relationships with doctors and nurses.
Its just that when you go and say, Im gonna be lling in an incident form about such and such. Theres kind of a look as if to say, Youre a traitor.. Youre meant to be on our side, you work on our ward. (Focus group 2: large teaching hospital with paper reporting systemdMale with 4 years pharmacy experience.)

Personal fears about reporting medication errors were raised by pharmacists in only 1 focus group and the feeling was that internal investigations, although valid, needed to be performed more sensitively. The incident The nature of the medication errors themselves was the most frequently identied issue that inuenced pharmacists decisions to report a medication incident or not. The vast majority of participants were in no doubt that the actual severity of a medication error overrode everything else when considering reporting, and that hospital pharmacists rst

Unless, the pharmacist was comfortable that the team they worked within was prepared for, and wanted them, to report the medication errors there was real hesitancy about reporting.

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think whether the patient came to any serious harm before considering whether to report.
I mean I always think of things in terms of could it prolong their stay in hospital or could It.similar to, I suppose, the adverse drug reactions really, where, you know, if it resulted in or prolonged hospital admission or caused them some damage of some description. (Focus group 1: small general hospital with paper reporting systemdFemale with 18 years pharmacy experience.)

with paper reporting systemdFemale with 6 years pharmacy experience.)

Incidents with only a potential for patient harm (including prescribing omission errors on admission to hospital detected through medicines reconciliation) were generally accepted as being as important in theory, but just occurring too frequently to be reported with any regularity.
[Because] if we reported every time something was missed o a patients drug history wed probably make a report about every patient. (Focus group 4: large teaching hospital with electronic reporting systemdFemale with 2 years pharmacy experience.)

Several participants highlighted a practice of sometimes reporting an incident to justify themselves and being more likely to report the same type of error made by pharmacists in the dispensary, rather than by doctors on ward. These both appear to refer back to the subthemes of a blame culture in some hospital working environments and anxieties about reporting other health professionals. It was clear from all focus group participants that each pharmacist held dierent thresholds for reporting medication errors dependent on a particular set of circumstances aected by the subthemes identied above.
The classic is everybodys got dierent thresholds for reporting dierent things. It probably varies on the day of the week and it varies on your mood.and it may be less on a Sunday than on a Monday. (Focus group 2: large teaching hospital with paper reporting systemdMale with 20 years pharmacy experience.)

The injustice to both patients and health professionals and the failure to possibly identify patterns of error by not reporting no harm errors were however accepted as negative consequences to this approach. A number of other subthemes emerged that indirectly linked the severity of the incident with the consideration to report, namely the drug itself, repetition of the error, and system or personal negligence type errors.
But methotrexate 2.5 and methotrexate 10 is exactly the same relationship as atenolol 25 and atenolol 100 but the results of muddling them up arent the same, but its the same error, so really you should be reporting them as an error type. Thats what I always feel.I wouldnt report the atenolol, but really you should because its exactly the same thing, isnt it. (Focus group 1: small general hospital with paper reporting systemd Female with 13 years pharmacy experience.) I dont know how I would dene signicant, but something that Id maybe seen a trend of, that might make me start thinking, This is a trend Im seeing, unless I start reporting this nobody else is going to see this. (Focus group 3: large general hospital with paper reporting systemdMale with 4 years pharmacy experience.) If you know a doctor who, on a regular occasion, makes the same error and if you dont ll out an incident form theyre never gonna get pulled up, whereas if you do ll an incident form then they might. (Focus group 2: large teaching hospital

The reporting system Incident reporting forms not exclusively designed for medication error reporting, paper or electronic, were felt by all to be cumbersome and had too many unnecessary elds that had to be completed.
Balance between what data set is workable, because pharmacists being pharmacists, give us a form, theres 60 boxes on it, well attempt to ll 60 boxes because thats what we do. (Focus group 2: large teaching hospital with paper reporting systemdMale with 20 years pharmacy experience.)

This appeared to mean that pharmacists either; did not complete the forms because of the amount of time needed; or because of anxieties about professional relationships they go to great lengths to complete the form to make sure they do not implicate a health professional incorrectly.
Not knowing the full detail of exactly the entire incident . Because you think, Im gonna have to go back and look through all the notes, blah-blahblah, and again its probably a time thing but if you dont know, you dont wanna lay the blame at somebody. (Focus group 2: large teaching hospital with paper reporting systemdFemale with 3 years pharmacy experience.)

The presence of more than 1 incident form appeared to cause misunderstanding and confusion

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about which types of errors should be reported, and on what forms. There was disagreement about the importance of anonymous reporting, with junior pharmacists condent that health professionals would know anyway if their ward pharmacist had reported them. Participants who had been exposed to an electronic reporting system disagreed whether it would be easier than a paper system. Learning There was universal agreement between participants about the perceived benets of reporting to improve medication safety by identifying persistent problems, to which solutions could then be found.
Obviously its really important that this doesnt happen again and if you didnt know then that means lots of other people didnt know about this and so I have to ll this form in to make sure that this gets identied by the Trust, so that it doesnt happen and other people get warned about this. (Focus group 1: small general hospital with paper reporting systemdFemale with 18 years pharmacy experience.)

or had worked, in a hospital pharmacy department demonstrating the positive benets of reporting and supporting their pharmacists to feel comfortable to do so.
Reective learning.encourages you to nd the reasons why. It doesnt have, because youre an idiot. on the list of reasons why the mistake was made, its Was it busy? What else was going on? What pressures were on you? And you start looking at the way you work. (Focus group 3: large general hospital with paper reporting systemdMale with 4 years pharmacy experience.) Weve got a massive, or weve got a major pedigree of changing things in terms of prescribing as a result of people agging issues up, and the issues could be agged up in a multitude of ways, but a clinical incident form might be one of the ways that are used to kind of like ag that up. (Focus group 2: large teaching hospital with paper reporting systemd Male with 20 years pharmacy experience.)

Improvements in reporting The need for pharmacists to not feel chastised by reporting and to receive positive feedback about errors, and any changes subsequently implemented, were regarded unanimously as the primary drivers to improve medication error reporting.
Knowing that what youre doing is actually being seen, read, heard by someone, and something is actually being done about it.And trying to get rid, trying to promote the open and learning, you know, so that people dont have this antiquated idea that were actually out to get them, that were actually trying to do it for the benet of not only the patient but their ward at the same, or their area at the same time. (Focus group 2: large teaching hospital with paper reporting systemdMale with 4 years pharmacy experience.)

There was however a clear split between the focus groups and their experiences of positive feedback and change following reported errors. Two of the focus groups described their frustration at not receiving formal feedback about errors reported, and even struggled to detail any changes that had occurred as a result of the error reporting.
I dont know how it works afterward. I dont know, how much does a team come and look at the notes and look at the patient cardex for them? I dont know how its followed up really. I know theyre e-mailed out to loads of people, Im not sure what the follow up procedure is.you never get feedback on ones youve reported yourself. (Focus group 4: large teaching hospital with electronic reporting systemdFemale with 1 years pharmacy experience.)

By contrast, 2 focus groups were pleased with the positive changes that had been made as a result of error reporting, even resulting in the funding of an additional pharmacist post.
I think weve done a good job in explaining the benets of why were doing it, its not just to come and hit you with a big stick, you know, and tell you what youre doing wrong. (Focus group 3: large general hospital with paper reporting systemd Male with 11 years pharmacy experience.)

Some pharmacists thought that the simple issuing of letters to reporters after an incident might help to improve reporting if they were more positive than Thank you very much we have received your form. Given the prevalence of medication errors in hospital proposals for improving reporting were centered around a simpler reporting system and reliance on targeted reporting by pharmacists.
People can become a bit snow-blind to kind of multiple reports of lots of things going on without any clear focus about what youre trying to do to improve it. So targeting certain sub-sections of a trust for monitoring a specic target is one area, but then deciding what you are gonna report and not gonna report is key. (Focus group 3: large general hospital with paper reporting systemdMale with 22 years pharmacy experience.)

Condence in reporting medication errors was unmistakable in those pharmacists who worked,

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Drug-specic error reporting forms with the simplest of data sets were considered the best practical way to improve reporting, with ideas including the use of other sta to fully report errors once the front line pharmacist had collected the basic information. There was general support that electronic forms/systems would be easier than paper ones but divided opinion as to the added benet of anonymous reporting.

Discussion This studys aim was to establish the attitudes of hospital pharmacists toward reporting medication errors. The pharmacists understood that it was part of their job to improve medication safety for patients through reporting errors. However, due to the endemic nature of medication errors, and busy hospital working environments, pharmacists do not report medication errors as often as they would wish. This is a very important barrier to reporting medication errors that appears unique to hospital pharmacists and participants agreed that the prevalence of medication errors has probably led to reporter apathy, which in turn has led to an acceptance of not reporting. The culture of blame, highlighted in the past 10 years of patient safety research,6,26 is recognized by pharmacists in UK hospitals, but in contrast to literature regarding UK community pharmacists17 and U.S. hospital pharmacists15, medical27 and nursing sta28 personal fears about litigation and disciplinary procedures because of reporting errors were not identied as a key concern. For many years, hospital pharmacists have strived to be accepted as equal partners in multidisciplinary clinical teams29,30 and to not be seen as policemen31, and this study found that they often hold specic anxieties about reporting medical and nursing sta because of those close working relationships. Hospital pharmacists, however, appear to have adopted strategies to reduce such tensions by either educating doctors at the time of an error, or just not reporting the incident at all. It is clear that, once happy to report, hospital pharmacists were similar to their medical and nursing colleagues28,32,33 in that the severity of any patient harm was undoubtedly the primary reporting driver. Pharmacists appeared to have dierent personal thresholds for reporting medication errors, but there was universal agreement that common prescribing errors of omission, discovered as part of the medicines reconciliation

process were unlikely to be reported unless serious harm had or was likely to have occurred. Reporting forms, unless designed specically for medication errors were considered too cumbersome and time consuming to complete. The detail conscious nature of pharmacists adds to their anxieties about interprofessional relationships as they feel that they have to nd and record every possible detail to ensure they do not incriminate a health professional unnecessarily. This concurs with the work of Coley et al,16 where the time-consuming nature of conrming and collecting medication error details was identied as a major barrier to reporting. This may be 1 plausible hypothesis for why pharmacists do not complete error reporting forms. The dierences between the focus groups showed clear evidence that positive feedback about errors and witnessing positive changes to systems following errors, rather than poor feedback and in action, may encourage pharmacists to feel more condent about reporting. This supports the ndings of Boyle et al18 in community pharmacies, and an improved hospital safety culture has been associated with less negative about barriers to reporting, leading to increased reporting.21,28,34 Participants in the focus groups were not randomly selected but self selected, after invitation from their departmental clinical pharmacy manager. It is possible that the sample may have only included pharmacists prepared to give an opinion on the topic that was in part about not following hospital guidance, when senior departmental colleagues may have also been present. The focus group facilitator was aware of these possible concerns and tried to keep pharmacists at ease when potentially dicult scenarios about errors were described. The total number of pharmacists participating in the focus groups was relatively small but with pharmacists with a wide range of experience from dierent sized and type of hospital with dierent safety cultures, it was sucient to ensure data saturation and to identify key attitudes to reporting. A large quantitative survey of hospital pharmacists is warranted to further explore and quantify the attitudes to reporting mediation errors identied in this qualitative study. Conclusion Hospital pharmacists understand the tance of reporting medication incidents prove patient safety, but due in part number of errors they encounter, they importo imto the do not

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Williams et al. / Research in Social and Administrative Pharmacy 9 (2013) 8089 12. Waring JJ. A qualitative study of the intra-hospital variations in incident reporting. Int J Qual Health Care 2004;16:347352. 13. Vincent C, Stanhope N, Crowley-Murphy M. Reasons for not reporting adverse incidents: an empirical study. J Eval Clin Pract 1999;5:1321. 14. Wakeeld DS, Wakeeld BJ, Uden-Holman T, Borders T, Blegen M, Vaughn T. Understanding why medication administration errors may not be reported. Am J Med Qual 1999;14:8188. 15. Tamuz M, Thomas EJ, Franchois KE. Dening and classifying medical error: lessons for patient safety reporting systems. Qual Saf Health Care 2004;13: 1320. 16. Coley KC, Pringle JL, Weber RJ, Rice K, Ramanujam R, Sirio CA. Perceived barriers in using a region-wide medication error reporting system. J Patient Saf 2006;2:3944. 17. Ashcroft DM, Morecroft C, Parker D, Noyce PR. Likelihood of reporting adverse events in community pharmacy: an experimental study. Qual Saf Health Care 2006;15:4852. 18. Boyle TA, Mahaey T, MacKinnon NJ, Deal H, Hallstrom LK, Morgan H. Determinants of medication incident reporting, recovery, and learning in community pharmacies: a conceptual model. Res Soc Adm Pharm 2011;7:93107. 19. Dornan T, Ashcroft D, Heatheld H, et al. An in depth investigation into causes of prescribing errors by foundation trainees in relation to their medical education. EQUIP study 2009. Available at: http:// www.gmc-uk.org/FINAL_Report_prevalence_and_ causes_of_prescribing_errors.pdf_28935150.pdf. Accessed 10.08.11. 20. Flynn EAB. Comparison of methods for detecting medication errors in 36 hospitals and skillednursing facilities. Am J Health Syst Pharm 2002;59: 436446. 21. Hutchinson A, Young TA, Cooper KL, et al. Trends in healthcare incident reporting and relationship to safety and quality data in acute hospitals: results from the National Reporting and Learning System. Qual Saf Health Care 2009; 18:510. 22. Williams SD, Ashcroft DM. Examining patient safety climate in the hospital pharmacy setting: a cross sectional survey. Int J Pharm Pract 2008; 16(suppl 3):C43C44. 23. Kingston MJ, Evans SM, Smith BJ, Berry JG. Attitudes of doctors and nurses towards incident reporting: a qualitative analysis. Med J Aust 2004;181: 3639. 24. Ritchie J, Spencer L. Qualitative data analysis of replied policy research. In: Bryman A, Burgess RG, eds. Analysing Qualitative Data. London and New York: Routledge; 1994. p. 173194. 25. Seston L, Hassell K. Pharmacy Workforce Census. London, UK: Royal Pharmaceutical Society of Great Britain; 2009.

report them as often as they should. They appear to have real anxieties that reporting will adversely aect their working relationships with medical and nursing sta but are more condent to report if they have seen positive changes following a reported incident. The decision to report an error is a complex process for hospital pharmacists that depend primarily on the severity of any patient harm, but it is unlikely for simple prescribing errors of omission, identied as part of medicines reconciliation on admission. The eort required to use reporting forms is compounded by pharmacists detail conscious nature fueling a desire to record every possible detail. References
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Williams et al. / Research in Social and Administrative Pharmacy 9 (2013) 8089 26. Coles J, Pryce D, Shaw C. The Reporting of Adverse Clinical IncidentsdAchieving High Quality Reporting: The Results of a Short Research Study. London, UK: CASPE Research; 2001. 27. Waring JJ. Beyond blame: cultural barriers to medical incident reporting. Soc Sci Med 2005;60: 19271935. 28. Blegen MA, Vaughn T, Pepper G, et al. Patient and sta safety: voluntary reporting. Am J Med Qual 2004;19:6774. 29. Broadhead RS, Fachinetta N. Drug iatrogenesis and clinical pharmacy. The mutual fate of a social problem and a professional movement. Soc Probl 1985; 32:425436. 30. Mesler MA. Boundary encroachment and task delegation: clinical pharmacists on the medical team. Sociol Health Illn 1991;13:310333. 31. Weiss MC. Clinical pharmacy: uncovering the hidden dimension. J Soc Adm Pharm 1994;11: 6771. 32. Throckmorton T, Etchegaray J. Factors aecting incident reporting by registered nurses: the relationship of perceptions of the environment for reporting errors, knowledge of the nursing practice act, and demographics on intent to report errors. J Perianesth Nurs 2007;22:400412. 33. Kreckler S, Catchpole K, McCulloch P, Handa A. Factors inuencing incident reporting in surgical care. Qual Saf Health Care 2009;18:116120. 34. Wakeeld BJ, Blegen MA, Uden-Holman T, Vaughn T, Chrischilles E, Wakeeld DS. Organizational culture, continuous quality improvement, and medication administration error reporting. Am J Med Qual 2001;16:128134.

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Prompts: Does it work well? Are there any problems with it? Do you have a pharmacy intervention monitoring scheme as well? Do you record incidents in the medical notes? What do you think is an ideal reporting system?  Are you clear what to report? Prompts: Any differences between near misses and actual incident? Does the severity of the incident make any difference? Use example Are you expected to report all medication errors? What dictates whether you actually do or dont report a medication error you come across?  What do you think is the primary purpose of reporting medication errors? Prompts: If we dont report errors how do we spread the message that occurred and work out how to reduce likelihood of happening again? Should it not be for the greater good?  Are you happy to report medication errors? Prompts: Any fears and if so what of? Any differences between self-reporting and reporting others? Any cultural issues? Issues about anonymity?  Can you give me any positive or negative examples of reporting? Prompts: Any changes made (or not made)/lessons learnt because of an incident?  What do you think patients views would be about whether pharmacists report medication errors? Prompts: Are you motivated to report for the benet of patients?  How often do you report medication errors?  Why is that hospital pharmacists dont report medication errors very well?  Are there any other barriers to reporting medication errors? Prompts: Any physical barriers, for example, time to ll out or ease of form. Concluding part Is there anything else you would like to talk about? Or anything you would like to go back to or add?

Appendix Focus group interview schedule Part 1: Background [brief] Can you tell me your current grade and the number of years that you have been qualied as a pharmacist? Part 2: Attitudes to medication error reporting [in depth] Prompts will be used to obtain more in-depth information as necessary  What does incident reporting/medication error reporting mean to you?  What system exists in your hospital for reporting medication errors