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Objectives: Medication is a common cause of preventable medical harm in pediatric inpatients. This study aimed to examine the sociotechnical system surrounding pediatric medicines management, to identify potential gaps in this system and how these might contribute to adverse drug events (ADEs)., Methods: An exploratory prospective qualitative study in pediatric wards in three hospitals in the north of England was conducted between October 2020 and May 2022. Analysis included a documentary analysis of 72 policies and procedures and analysis of field notes from 60 hours of participant observation. The cognitive work analysis prompt framework was used to generate a work domain analysis (WDA) and identify potential contributory factors to ADEs., Results: The WDA identified 2 functional purposes, 7 value/priority measures, 6 purpose-related functions, 11 object-related processes and 14 objects. Structured means-ends connections supported identification of 3 potential contributory factors-resource limitations, cognitive demands, and adaptation of processes. The lack of resources (equipment, materials, knowledge, and experience) created an environment where distractions and interruptions were unavoidable. Families helped provide practical support in medicines administration but were largely unacknowledged at an organizational level. There was a lack of teamwork with regards to medication with different professionals responsible for different parts of the system. Mandated safety checks on medicines were frequently omitted because of limited resources and perceived redundancy. Interventions to support adherence to safety policies were also often bypassed because they created more work., Conclusions: The WDA has provided insights into the complex system of medication safety for children in hospital and has facilitated the identification of potential contributory factors to ADEs. We therefore advocate (in priority order) for processes to involve parents in the care of their children in hospital, development of skill-mix interventions to ensure appropriate expertise is available where it is needed, and modified checking procedures to permit staff to use their skills and judgment effectively and efficiently., Competing Interests: The authors disclose no conflict of interest., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Intensive care patients surviving to transfer to a lower-acuity hospital ward experience ongoing challenges to their recovery and lack a well-defined and developed care pathway. The transfer process to a hospital ward exposes intensive care patients to high rates of medication errors, which increase their risk of adverse drug events., Objective: The aims of this study were to identify priorities for medication-related intervention components and outcome measures for improving medication safety for intensive care patients transferring to a hospital ward., Methods: Three panels involving 129 participants covering (i) intensive care, (ii) hospital ward health-care professionals and (iii) public representatives completed an electronic Delphi survey conducted over three phases. The Delphi process comprised three sections (medication-related intervention components, medication outcomes and patient outcomes). Items were graded in their level of importance, with predefined important criteria. Item agreement required consensus across all three panels. Intervention barriers and facilitators identified in participant comments were categorized according to a socio-technical systems approach to the patient journey and patient safety (Systems Engineering Initiative for Patient Safety 3.0 model)., Results: Of the 129 (84.5%) participants, 109 completed all three Delphi phases. Consensus was achieved for 48 intervention components, 13 medication outcome measures and 11 patient outcome measures. Phase 1 provided 158 comments comprising >200 individual barriers and facilitators to intervention delivery. Frequently cited facilitators included clearly specified roles and responsibilities (10.7% (organizational conditions)), patient and family as agents (8.8% (care team)), medicines-related information easily accessible (7.8% (tools and technologies)) and clear medication plan and communication (7.3% (tasks))., Conclusions: Our findings provide identification of priorities for medication-related intervention components to improve medication safety for intensive care patients transferring to a hospital ward. Prioritization is complemented by the identification and socio-technical categorization of barriers and facilitators to intervention delivery. The identified important medication and patient outcomes to measure will inform the design of a future patient medication safety intervention study., (© The Author(s) 2022. Published by Oxford University Press on behalf of International Society for Quality in Health Care.)

Introduction: The 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., Method: Focus 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., Results: Overall, 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., Discussion: This 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., Competing Interests: The authors have declared that no competing interests exist.

Background: Medication safety incidents commonly occur in mental health hospitals. There is a need to improve the understanding of the circumstances that are thought to have played a part in the origin of these incidents to design safer systems to improve patient safety., Aim: This study aimed to undertake a mixed-methods analysis of medication safety incidents reported to the National Reporting and Learning System in England and Wales in 2010 to 2017., Method: Quantitative analyses of anonymized medication safety incidents occurring in mental health hospitals that were reported to the National Reporting and Learning System during an 8-year period were undertaken to characterize their type, severity, and the medication(s) involved. Second, a content analysis of the free-text reports associated with all incidents of at least moderate harm severity was undertaken to identify the underlying contributory factors., Results: Overall, 94,134 medication incident reports were examined, of which 10.4% (n = 9811) were reported to have resulted in harm. The 3 most frequent types of reported medication incidents involved omission of medication (17,302; 18.3%), wrong frequency (11,882; 12.6%), and wrong/unclear dose of medication (10,272; 10.9%). Medicines from the central nervous system (42,609; 71.0%), cardiovascular (4537; 7.6%), and endocrine (3669; 6.1%) medication classes were the most frequently involved with incidents. Failure to follow protocols (n = 93), lack of continuity of care (n = 92), patient behaviors (n = 62), and lack of stock (n = 51) were frequently reported as contributory factors., Conclusions: Medication incidents pose an enduring threat to patient safety in mental health hospitals. This study has identified important targets that can guide the tailored development of remedial interventions., Competing Interests: The authors disclose no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Critically ill neonates and paediatric patients may be at a greater risk of medication-related safety incidents than those in other clinical areas., Objective: This study aimed to examine the nature of, and contributory factors associated with, medication-related safety incidents reported in neonatal and paediatric intensive care units (ICUs)., Methods: We carried out a mixed-methods analysis of anonymised medication safety incidents reported to the National Reporting and Learning System that involved children (aged ≤ 18 years) admitted to ICUs across England and Wales over a 9-year period (2010-2018). Data were analysed descriptively, and free-text descriptions of harmful incidents were examined to explore potential contributory factors associated with incidents., Results: In total, 25,567 eligible medication-related incident reports were examined. Incidents commonly occurred during the medicines administration (n = 13,668 [53.5%]) and prescribing stages (n = 7412 [29%]). The most commonly implicated error types were drug omission (n = 4812 [18.8%]) and dosing errors (n = 4475 [17.5%]). Neonates were commonly involved in reported incidents (n = 12,235 [47.9%]). Anti-infectives (n = 6483 [25.4%]) were the medications most commonly associated with incidents and commonly involved neonates. Incidents that were reported to have caused patient harm accounted for 12.2% (n = 3129) and commonly involved neonates (n = 1570/3129 [50.2%]). Common contributing factors to harmful incidents included staff-related factors (68.7%), such as failure to follow protocols or errors in documentation, which were often associated with working conditions, inadequate guidelines, and design of systems and protocols., Conclusions: Neonates were commonly involved in medication-related incidents reported in children's intensive care settings. Improvements in staffing and workload, design of systems and processes, and the use of anti-infective medications may reduce this risk.

Objectives: Medication safety incidents are common in primary care and contributory factors frameworks can assist in our understanding of their causes. A framework that is positioned from the perspective of patients would be advantageous in practice when seeking patient insights into medication safety. The aim of this study was to develop a patient-centered contributory factors framework for examining medication safety incidents., Methods: A purposive sample of 106 members of the public, patients, and carers were recruited to take part in focus groups (n = 18). Focus groups were audio recorded, transcribed, and analyzed using a thematic framework. A patient and public involvement group was set up to undertake multiple roles in the research process, including the development of the focus group schedule, analysis of the data, and the construction of a patient-centered framework of contributory factors (patient-centered medication safety) and implementation checklist., Results: The findings highlighted the importance of communication, supplies of medication and appliances, patient- and carer-related factors, healthcare professional factors, and computer systems and programs in the safe use of medicines. Some contributory factors were unique to primary care patients such as access to services and continuity of care. In conjunction with a patient and public involvement group, a framework of factors that patients believe contribute to medication safety incidents in primary care was developed that could be used by patients and healthcare professionals., Conclusions: The patient-centered medication safety framework and implementation checklist provides a novel tool to examine contributory factors that can lead to medication safety incidents from patients' perspective.

Background: We evaluated the impact of the pharmacist-led Safety Medication dASHboard (SMASH) intervention on medication safety in primary care., Methods and Findings: SMASH comprised (1) training of clinical pharmacists to deliver the intervention; (2) a web-based dashboard providing actionable, patient-level feedback; and (3) pharmacists reviewing individual at-risk patients, and initiating remedial actions or advising general practitioners on doing so. It was implemented in 43 general practices covering a population of 235,595 people in Salford (Greater Manchester), UK. All practices started receiving the intervention between 18 April 2016 and 26 September 2017. We used an interrupted time series analysis of rates (prevalence) of potentially hazardous prescribing and inadequate blood-test monitoring, comparing observed rates post-intervention to extrapolations from a 24-month pre-intervention trend. The number of people registered to participating practices and having 1 or more risk factors for being exposed to hazardous prescribing or inadequate blood-test monitoring at the start of the intervention was 47,413 (males: 23,073 [48.7%]; mean age: 60 years [standard deviation: 21]). At baseline, 95% of practices had rates of potentially hazardous prescribing (composite of 10 indicators) between 0.88% and 6.19%. The prevalence of potentially hazardous prescribing reduced by 27.9% (95% CI 20.3% to 36.8%, p < 0.001) at 24 weeks and by 40.7% (95% CI 29.1% to 54.2%, p < 0.001) at 12 months after introduction of SMASH. The rate of inadequate blood-test monitoring (composite of 2 indicators) reduced by 22.0% (95% CI 0.2% to 50.7%, p = 0.046) at 24 weeks; the change at 12 months (23.5%) was no longer significant (95% CI -4.5% to 61.6%, p = 0.127). After 12 months, 95% of practices had rates of potentially hazardous prescribing between 0.74% and 3.02%. Study limitations include the fact that practices were not randomised, and therefore unmeasured confounding may have influenced our findings., Conclusions: The SMASH intervention was associated with reduced rates of potentially hazardous prescribing and inadequate blood-test monitoring in general practices. This reduction was sustained over 12 months after the start of the intervention for prescribing but not for monitoring of medication. There was a marked reduction in the variation in rates of hazardous prescribing between practices., Competing Interests: I have read the journal's policy and the authors of this manuscript have the following competing interests: RNK has received an honorarium for presenting on the topic of schizophrenia (epidemiology, aetiology, presentation and management) at the MORPh Consultancy Ltd Primary Care Pharmacists Training Network Mental Health Event, on 23rd October 2019, Liverpool UK.

Background: Improving medication safety is a major concern in primary care settings worldwide. The Salford Medication safety dASHboard (SMASH) intervention provided general practices in Salford (Greater Manchester, UK) with feedback on their safe prescribing and monitoring of medications through an online dashboard, and input from practice-based trained clinical pharmacists. In this study we explored how staff working in general practices used the SMASH dashboard to improve medication safety, through interactions with the dashboard to identify potential medication safety hazards and their workflow to resolve identified hazards., Methods: We used a mixed-methods study design involving quantitative data from dashboard user interaction logs from 43 general practices during the first year of receiving the SMASH intervention, and qualitative data from semi-structured interviews with 22 pharmacists and physicians from 18 practices in Salford., Results: Practices interacted with the dashboard a median of 12.0 (interquartile range, 5.0-15.2) times per month during the first quarter of use to identify and resolve potential medication safety hazards, typically starting with the most prevalent hazards or those they perceived to be most serious. Having observed a potential hazard, pharmacists and practice staff worked together to resolve that in a sequence of steps (1) verifying the dashboard information, (2) reviewing the patient's clinical records, and (3) deciding potential changes to the patient's medicines. Over time, dashboard use transitioned towards regular but less frequent (median of 5.5 [3.5-7.9] times per month) checks to identify and resolve new cases. The frequency of dashboard use was higher in practices with a larger number of at-risk patients. In 24 (56%) practices only pharmacists used the dashboard; in 12 (28%) use by other practice staff increased as pharmacist use declined after the initial intervention period; and in 7 (16%) there was mixed use by both pharmacists and practice staff over time., Conclusions: An online medication safety dashboard enabled pharmacists to identify patients at risk of potentially hazardous prescribing. They subsequently worked with GPs to resolve risks on a case-by-case basis, but there were marked variations in processes between some practices. Workload diminished over time as it shifted towards resolving new cases of hazardous prescribing.

Objective: Limited evidence concerning the burden and predictors of omitted medication doses within mental health hospitals could severely limit improvement efforts in this specialist setting. This study aimed to determine the prevalence, nature and predictors of omitted medication doses affecting hospital inpatients in two English National Health Service (NHS) mental health trusts., Methods: Over 6 data collection days trained pharmacy teams screened inpatient prescription charts for scheduled and omitted medication doses within 27 adult and elderly wards across 9 psychiatric hospitals. Data were collected for inpatients admitted up to two weeks prior to each data collection day. Omitted doses were classified as 'time critical' and 'preventable' based on established criteria. Omitted dose frequencies were presented with 95% confidence intervals (CI). Multilevel logistic regression analyses determined the predictors of omitted dose occurrence, with omission risks presented as adjusted odds ratios (OR) with 95% CI., Results: 18,664 scheduled medication doses were screened for 444 inpatients and 2,717 omissions were identified, resulting in a rate of 14.6% (95% CI 14.1-15.1). The rate of 'time critical' omitted doses was 19.3% (95% CI 16.3-22.6%). 'Preventable' omitted doses comprised one third of all omissions (34.5%, 930/2694). Logistic regression analysis revealed that medicines affecting the central nervous system were 55% less likely to be omitted compared to all other medication classes (9.9% vs. 18.8%, OR 0.45 (0.40-0.52)) and that scheduled doses administered using non-oral routes were more likely to be omitted compared the oral route (inhaled OR 3.47 (2.64-4.57), topical 2.71 (2.11-3.46), 'other' 2.15 (1.19-3.90)). 'Preventable' dose omissions were more than twice as likely to occur for 'time critical' medications than non-time critical medications (50.4% vs. 33.8%, OR 2.24 (1.22-4.11))., Conclusions: Omitted medication doses occur commonly in mental health hospitals with 'preventable' omissions a key contributor to this burden. Important targets for remedial intervention have been identified., Competing Interests: The authors have declared that no competing interests exist.

Background: Problems arising from medicines usage are recognised as a key patient safety issue. Children are a particular concern, given that they are more likely than adults to experience medication-related harm. While previous reviews have provided an estimate of prevalence in this population, these predate recent developments in the delivery of paediatric care. Hence, there is a need for an updated, focussed and critical review of the prevalence and nature of drug-related problems in hospitalised children in the UK, in order to support the development and targeting of interventions to improve medication safety., Methods: Nine electronic databases (Medline, Embase, CINAHL, PsychInfo, IPA, Scopus, HMIC, BNI, The Cochrane library and clinical trial databases) were searched from January 1999 to April 2019. Studies were included if they were based in the UK, reported on the frequency of adverse drug reactions (ADRs), adverse drug events (ADEs) or medication errors (MEs) affecting hospitalised children. Quality appraisal of the studies was also conducted., Results: In all, 26 studies were included. There were no studies which specifically reported prevalence of adverse drug events. Two adverse drug reaction studies reported a median prevalence of 25.6% of patients (IQR 21.8-29.9); 79.2% of reactions warranted withdrawal of medication. Sixteen studies reported on prescribing errors (median prevalence 6.5%; IQR 4.7-13.3); of which, the median rate of dose prescribing errors was 11.1% (IQR 2.9-13). Ten studies reported on administration errors with a median prevalence of 16.3% (IQR 6.4-23). Administration technique errors represented 53% (IQR 52.7-67.4) of these errors. Errors detected during medicines reconciliation at hospital admission affected 43% of patients, 23% (Range 20.1-46) of prescribed medication; 70.3% (Range 50-78) were classified as potentially harmful. Medication errors detected during reconciliation on discharge from hospital affected 33% of patients and 19.7% of medicines, with 22% considered potentially harmful. No studies examined the prevalence of monitoring or dispensing errors., Conclusions: Children are commonly affected by drug-related problems throughout their hospital journey. Given the high prevalence and risk of patient harm,, there is a need for a deeper theoretical understanding of paediatric medication systems to enable more effective interventions to be developed to improve patient safety.

Introduction: Children admitted to paediatric and neonatal intensive care units may be at high risk from medication errors and preventable adverse drug events., Objective: The objective of this systematic review was to review empirical studies examining the prevalence and nature of medication errors and preventable adverse drug events in paediatric and neonatal intensive care units., Data Sources: Seven electronic databases were searched between January 2000 and March 2019., Study Selection: Quantitative studies that examined medication errors/preventable adverse drug events using direct observation, medication chart review, or a mixture of methods in children ≤ 18 years of age admitted to paediatric or neonatal intensive care units were included., Data Extraction: Data on study design, detection method used, rates and types of medication errors/preventable adverse drug events, and medication classes involved were extracted., Results: Thirty-five unique studies were identified for inclusion. In paediatric intensive care units, the median rate of medication errors was 14.6 per 100 medication orders (interquartile range 5.7-48.8%, n = 3) and between 6.4 and 9.1 per 1000 patient-days (n = 2). In neonatal intensive care units, medication error rates ranged from 4 to 35.1 per 1000 patient-days (n = 2) and from 5.5 to 77.9 per 100 medication orders (n = 2). In both settings, prescribing and medication administration errors were found to be the most common medication errors, with dosing errors the most frequently reported error subtype. Preventable adverse drug event rates were reported in three paediatric intensive care unit studies as 2.3 per 100 patients (n = 1) and 21-29 per 1000 patient-days (n = 2). In neonatal intensive care units, preventable adverse drug event rates from three studies were 0.86 per 1000 doses (n = 1) and 0.47-14.38 per 1000 patient-days (n = 2). Anti-infective agents were commonly involved with medication errors/preventable adverse drug events in both settings., Conclusions: Medication errors occur frequently in critically ill children admitted to paediatric and neonatal intensive care units and may lead to patient harm. Important targets such as dosing errors and anti-infective medications were identified to guide the development of remedial interventions.

Objective: To characterise the use of an electronic medication safety dashboard by exploring and contrasting interactions from primary users (i.e. pharmacists) who were leading the intervention and secondary users (i.e. non-pharmacist staff) who used the dashboard to engage in safe prescribing practices., Materials and Methods: We conducted a 10-month observational study in which 35 health professionals used an instrumented medication safety dashboard for audit and feedback purposes in clinical practice as part of a wider intervention study. We modelled user interaction by computing features representing exploration and dwell time through user interface events that were logged on a remote database. We applied supervised learning algorithms to classify primary against secondary users., Results: We observed values for accuracy above 0.8, indicating that 80% of the time we were able to distinguish a primary user from a secondary user. In particular, the Multilayer Perceptron (MLP) yielded the highest values of precision (0.88), recall (0.86) and F-measure (0.86). The behaviour of primary users was distinctive in that they spent less time between mouse clicks (lower dwell time) on the screens showing the overview of the practice and trends. Secondary users exhibited a higher dwell time and more visual search activity (higher exploration) on the screens displaying patients at risk and visualisations., Discussion and Conclusion: We were able to distinguish the interactive behaviour of primary and secondary users of a medication safety dashboard in primary care using timestamped mouse events. Primary users were more competent on population health monitoring activities, while secondary users struggled on activities involving a detailed breakdown of the safety of patients. Informed by these findings, we propose workflows that group these activities and adaptive nudges to increase user engagement., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Objective: To determine the prevalence, nature and predictors of patients having medication administration omissions in hospitals., Methods: All medication administration omissions data collected using the standardised methodology of the Medication Safety Thermometer in January 2015 were examined. Hospital inpatients prescribed at least one medication were included in the analysis. Multilevel logistic regression models ascertained the effects of patients' gender, age, number of prescribed medicines, ward specialty and medicines reconciliation initiation status on the likelihood of having omissions. Valid clinical reasons (VCRs) were excluded from regression models. A sensitivity analysis, excluding patient refusal (PR) omissions, was also conducted., Results: The final study sample included 5708 patients from 320 wards in 37 hospitals. Excluding VCRs, 30% of patients had medication administration omissions (95% CI 29 to 30). Approximately half of patients with omissions had refused medicines (51%, 95% CI 49 to 53). Univariable analysis suggested that all variables were significantly associated with omissions. However, in the multivariable model, significant differences were only observed regarding the numbers of medicines patients were prescribed and their ward specialty. Patients prescribed more than 20 medications were approximately five times more likely to have had omissions than patients prescribed one to four medications (OR 4.99, 95% CI 3.22 to 7.73). Patients on surgical wards were also more likely to have had omissions than those on medical wards (OR 1.58, 95% CI 1.14 to 2.18, p=0.006), but there was no significant difference when PRs were excluded (OR 0.5, 95% CI 0.27 to 1.22, p=0.473)., Conclusion: Medication administration omissions are a substantial problem that affect many hospital patients, and certain patient groups are at higher risk. Specific interventions are required targeting the underlying reasons for medication omissions for different patient subgroups., Competing Interests: Competing interests: The first author of this article, PR, has the following competing interests: he is a PhD student funded by Haelo who facilitated the initial development of the tool being evaluated in the study. However, PR is based at the University of Manchester and Haelo had no role in the study design., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To explore the factors contributing to prescribing error in paediatric intensive care units (PICUs) using a human factors approach based on Reason's theory of error causation to support planning of interventions to mitigate slips and lapses, rules-based mistakes and knowledge-based mistakes., Methods: A hierarchical task analysis (HTA) of prescribing was conducted using documentary analysis. Eleven semistructured interviews with prescribers were conducted using vignettes and were analysed using template analysis. Contributory factors were identified through the interviews and were related to tasks in the HTA by an expert panel involving a PICU clinician, nurse and pharmacist., Results: Prescribing in PICU is composed of 30 subtasks. Our findings indicate that cognitive burden was the main contributory factor of prescribing error. This manifested in two ways: physical, associated with fatigue, distraction and interruption, and poor information transfer; and psychological, related to inexperience, changing workload and insufficient decision support information. Physical burden was associated with errors of omission or selection; psychological burden was linked to errors related to a lack of knowledge and/or awareness. Social control through nursing staff was the only identified control step. This control was dysfunctional at times as nurses were part of an informal mechanism to support decision making, was ineffective., Conclusions: Cognitive burden on prescribers is the principal latent factor contributing to prescribing error. This research suggests that interventions relating to skill mix, and communication and presentation of information may be effective at mitigating rule and knowledge-based mistakes. Mitigating fatigue and standardising procedures may minimise slips and lapses., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Of the various types of medication administration error that occur in hospitals, dose omissions are consistently reported as among the most common. It has been suggested that greater involvement from pharmacy teams could help address this problem. A pilot service, called pharmacy TECHnician supported MEDicines administration (TECHMED), was introduced in an English NHS hospital for a four-week period in order to reduce preventable medication dose omissions. The objective of this study was to evaluate the implementation, delivery and impact of the pilot TECHMED service using qualitative methods., Methods: Semi-structured interviews with pharmacy technicians, nursing staff and senior management involved with the pilot service were undertaken to evaluate TECHMED. Interviews were transcribed verbatim and analysed using the framework approach, guided by Weiss's Theory Based Evaluation model., Results: Twenty-two stakeholder interviews were conducted with 10 ward-based pharmacy technicians, nine nurses and three members of senior management. Most technicians performed a range of activities in line with the service specification, including locating drugs from a variety of sources, and identified situations where they had prevented missing doses. Nurses reported positive impacts of TECHMED on workload. However, not all technicians fully adhered to the service specification in regard to directly following nursing staff during each medication round, citing reasons related to productivity or perceived intrusiveness towards nursing staff. Some participants also reported a perceived lack of impact of TECHMED on medicine omissions. Seventeen of the 22 interviewees supported an extension of the service. There were however, concerns about the impact on technician workload and some participants advocated support for targeted service extension to wards/rounds with high schedule dose volumes and omitted dose rates., Conclusions: The findings of this study suggest that the implementation of a pharmacy technician-supported medicines administration scheme to reduce omitted doses may be acceptable to staff in an NHS hospital, and that issues with service fidelity, staff resource/capacity and perceived interventions to avoid dose omissions have important implications for the feasibility of extending the service. The study has identified targets for future development in relation to individual and system factors to improve operationalisation of technician-led initiatives to reduce medicines omissions.

Background: There is a need to ensure that the risks associated with medication usage in primary health care are controlled. To maintain an understanding of the risks, health-care organizations may engage in a process known as "mindful organizing." While this is typically conceived of as involving organizational members, it may in the health-care context also include patients. Our study aimed to examine ways in which patients might contribute to mindful organizing with respect to primary care medication safety., Method: Qualitative focus groups and interviews were carried out with 126 members of the public in North West England and the East Midlands. Participants were taking medicines for a long-term health condition, were taking several medicines, had previously encountered problems with their medication or were caring for another person in any of these categories. Participants described their experiences of dealing with medication-related concerns. The transcripts were analysed using a thematic method., Results: We identified 4 themes to explain patient behaviour associated with mindful organizing: knowledge about clinical or system issues; artefacts that facilitate control of medication risks; communication with health-care professionals; and the relationship between patients and the health-care system (in particular, mutual trust)., Conclusions: Mindful organizing is potentially useful for framing patient involvement in safety, although there are some conceptual and practical issues to be addressed before it can be fully exploited in this setting. We have identified factors that influence (and are strengthened by) patients' engagement in mindful organizing, and as such would be a useful focus of efforts to support patient involvement., (© 2018 The Authors Health Expectations published by John Wiley & Sons Ltd.)

Objective: Medication administration errors (MAEs) are a common risk to patient safety in mental health hospitals, but an absence of in-depth studies to understand the underlying causes of these errors limits the development of effective remedial interventions. This study aimed to investigate the causes of MAEs affecting inpatients in a mental health National Health Service (NHS) hospital in the North West of England., Methods: Registered and student mental health nurses working in inpatient psychiatric units were identified using a combination of direct advertisement and incident reports and invited to participate in semi-structured interviews utilising the critical incident technique. Interviews were designed to capture the participants' experiences of inpatient MAEs. All interviews were transcribed verbatim and subject to framework analysis to illuminate the underlying active failures, error/violation-provoking conditions and latent failures according to Reason's model of accident causation., Results: A total of 20 participants described 26 MAEs (including 5 near misses) during the interviews. The majority of MAEs were skill-based slips and lapses (n = 16) or mistakes (n = 5), and were caused by a variety of interconnecting error/violation-provoking conditions relating to the patient, medicines used, medicines administration task, health care team, individual nurse and working environment. Some of these local conditions had origins in wider organisational latent failures. Recurrent and influential themes included inadequate staffing levels, unbalanced staff skill mix, interruptions/distractions, concerns with how the medicines administration task was approached and problems with communication., Conclusions: To our knowledge this is the first published in-depth qualitative study to investigate the underlying causes of specific MAEs in a mental health hospital. Our findings revealed that MAEs may arise due to multiple interacting error and violation provoking conditions and latent 'system' failures, which emphasises the complexity of this everyday task facing practitioners in clinical practice. Future research should focus on developing and testing interventions which address key local and wider organisational 'systems' failures to reduce error., Competing Interests: The authors have declared that no competing interests exist.

Background: Patient safety is vital to well-functioning health systems. A key component is safe prescribing, particularly in primary care where most medications are prescribed. Previous research demonstrated that the number of patients exposed to potentially hazardous prescribing can be reduced by interrogating the electronic health record (EHR) database of general practices and providing feedback to general practitioners in a pharmacist-led intervention. We aimed to develop and roll out an online dashboard application that delivers this audit and feedback intervention in a continuous fashion., Method: Based on initial system requirements we designed the dashboard's user interface over 3 iterations with 6 general practitioners (GPs), 7 pharmacists and a member of the public. Prescribing safety indicators from previous work were implemented in the dashboard. Pharmacists were trained to use the intervention and deliver it to general practices., Results: A web-based electronic dashboard was developed and linked to shared care records in Salford, UK. The completed dashboard was deployed in all but one (n=43) general practices in the region. By November 2017, 36 pharmacists had been trained in delivering the intervention to practices. There were 135 registered users of the dashboard, with an average of 91 user sessions a week., Conclusion: We have developed and successfully rolled out of a complex, pharmacist-led dashboard intervention in Salford, UK. System usage statistics indicate broad and sustained uptake of the intervention. The use of systems that provide regularly updated audit information may be an important contributor towards medication safety in primary care.

Background: While efforts have been made to bring about quality and safety improvement in healthcare, it remains by no means certain that an improvement project will succeed. This suggests a need to better understand the process and conditions of improvement. The current study addresses this question by examining English community pharmacies attempting to undertake improvement activities., Method: The study used a longitudinal qualitative design, involving a sample of ten community pharmacies. Each pharmacy took part in a series of improvement workshops, involving use of the Manchester Patient Safety Framework (MaPSaF), over a twelve-month period. Qualitative data were collected from the workshops, from follow-up focus groups and from field notes. Template analysis was used to identify themes in the data., Results: The progress made by pharmacies in improving their practice can be described in terms of a behavioural change framework, consisting of contemplation (resolving to make changes if they are required), planning (deciding how to carry out change) and execution (carrying out and reflecting on change). Organizational conditions supporting change were identified; these included the prioritisation of improvement, a commitment to change, a trusting and collaborative relationship between staff and managers, and knowledge about quality and safety issues to work on., Conclusions: Our study suggests a process by which healthcare work units might undergo improvement. In addition to recognising and providing support for this process, it is important to establish an environment that fosters improvement, and for work units to ensure that they are prepared for undergoing improvement activities.

Introduction: Little is known about the frequency and nature of medication errors (MEs) and adverse drug events (ADEs) that occur in mental health hospitals., Objectives: This systematic review aims to provide an up-to-date and critical appraisal of the epidemiology and nature of MEs and ADEs in this setting., Method: Ten electronic databases were searched, including MEDLINE, Embase, CINAHL, International Pharmaceutical Abstracts, PsycINFO, Scopus, British Nursing Index, ASSIA, Web of Science, and Cochrane Database of Systematic Reviews (1999 to October 2016). Studies that examined the rate of MEs or ADEs in mental health hospitals were included, and quality appraisal of the included studies was conducted., Result: In total, 20 studies were identified. The rate of MEs ranged from 10.6 to 17.5 per 1000 patient-days (n = 2) and of ADEs from 10.0 to 42.0 per 1000 patient-days (n = 2) with 13.0-17.3% of ADEs found to be preventable. ADEs were rated as clinically significant (66.0-71.0%), serious (28.0-31.0%), or life threatening (1.4-2.0%). Prescribing errors occurred in 4.5-6.3% of newly written or omitted prescription items (n = 3); dispensing errors occurred in 4.6% of opportunities for error (n = 1) and in 8.8% of patients (n = 1); and medication administration errors occurred in 3.3-48.0% of opportunities for error (n = 5). MEs and ADEs were frequently associated with psychotropics, with atypical antipsychotic drugs commonly involved. Variability in study setting and data collection methods limited direct comparisons between studies., Conclusion: Medication errors occur frequently in mental health hospitals and are associated with risk of patient harm. Effective interventions are needed to target these events and improve patient safety.

Quality Issue: Approximately 10% of patients are harmed by healthcare, and of this harm 15% is thought to be medication related. Despite this, medication safety data used for improvement purposes are not often routinely collected by healthcare organizations over time., Initial Assessment: A need for a prospective medication safety measurement tool was identified., Choice of Solution: The aim was to develop a tool to allow measurement and aid improvement of medication safety over time. The methodology used for the National Health Service (NHS) Safety Thermometer was identified as an approach. The resulting tool was named the 'Medication Safety Thermometer'., Implementation: The development of the Medication Safety Thermometer was facilitated by a multidisciplinary steering group using a Plan, Do, Study, Act (PDSA) method. Alpha and beta testing occurred over a period of 9 months. The tool was officially launched in October 2013 and continued to be improved until May 2016 using ongoing user feedback., Evaluation: Feedback was gained through paper and online forms, and was discussed at regular steering group meetings. This resulted in 16 versions of the tool. The tool is now used nationally, with over 230 000 patients surveyed in over 100 NHS organizations. Data from these organizations are openly accessible on a dedicated website., Lessons Learned: Measuring harm from medication errors is complex and requires steps to measure individual errors, triggers of harm and actual harm. PDSA methodology can be effectively used to develop measurement systems. Measurement at the point of care is beneficial and a multidisciplinary approach is vital., (© The Author 2016. Published by Oxford University Press in association with the International Society for Quality in Health Care.)

Objectives: To explore the combined use of a critical incident database and work domain analysis to understand patient safety issues in a health-care setting., Method: A retrospective review was conducted of incidents reported to the UK National Reporting and Learning System (NRLS) that involved community pharmacy between April 2005 and August 2010. A work domain analysis of community pharmacy was constructed using observational data from 5 community pharmacies, technical documentation, and a focus group with 6 pharmacists. Reports from the NRLS were mapped onto the model generated by the work domain analysis., Results: Approximately 14,709 incident reports meeting the selection criteria were retrieved from the NRLS. Descriptive statistical analysis of these reports found that almost all of the incidents involved medication and that the most frequently occurring error types were dose/strength errors, incorrect medication, and incorrect formulation. The work domain analysis identified 4 overall purposes for community pharmacy: business viability, health promotion and clinical services, provision of medication, and use of medication. These purposes were served by lower-order characteristics of the work system (such as the functions, processes and objects). The tasks most frequently implicated in the incident reports were those involving medication storage, assembly, or patient medication records., Conclusions: Combining the insights from different analytical methods improves understanding of patient safety problems. Incident reporting data can be used to identify general patterns, whereas the work domain analysis can generate information about the contextual factors that surround a critical task.

Background: Among the many stresses faced by pharmacy staff, quality related event (QRE) learning can be among the most significant. In the absence of a supportive organizational culture, the potential for blaming individuals, versus identifying key process flaws, is significant and can be very intimidating to those involved in such discussions and may increase an already stressful work environment., Objective: This research develops and tests a model of the relationship between the work stress faced by pharmacists and the extent of QRE learning in community pharmacies. Building upon recent research models that explore job characteristics and safety climate, the model proposes that work stress captured by the effort that the pharmacist invests into job performance, the extent to which the pharmacist is rewarded for such efforts, and the extent of pharmacist work-related commitment to their job, influence pharmacist assessment of the working conditions within their community pharmacy. It is further proposed that working conditions influence the extent of a blame culture and safety focus in the pharmacy, which, in turn, influences organizational learning from QREs., Methods: This research formed part of a larger study focused on QRE reporting in community pharmacies. As part of the larger study, a total of 1035 questionnaires were mailed to community pharmacists, pharmacy managers, and pharmacy owners in the Canadian province of Saskatchewan during the fall of 2013 and winter and spring of 2014. Partial least squares (PLS) using SmartPLS was selected to test and further develop the proposed model. An examination of the statistical significance of latent variable paths, convergent validity, construct reliability, discriminant validity, and variance explained was used to assess the overall quality of the model., Results: Of the 1035 questionnaire sent, a total of 432 questionnaires were returned for an initial response rate of approximately 42%. However, for this research, only questionnaires from staff pharmacists were used thereby reducing the number of usable questionnaires to 265. The final model highlights that pharmacist work stress greatly influences perceptions of the working conditions in the pharmacy (R(2) = 0.52), which, in turn, influence assessments of the safety focus (R(2) = 0.27) and blame culture (R(2) = 0.14) in the pharmacy. The model also found that the extent of a safety focus and blame culture within the pharmacy both influence the extent of organizational learning from QREs (R(2) = 0.44) within the pharmacy., Conclusions: In an environment where financial rewards are not always possible, ensuring that pharmacy staff feel respected and encouraged in providing safe care may help enhance QRE learning. Given the importance placed on organizational reporting of, and learning from, QREs in many jurisdictions in North America, the findings from this study suggest that a number of working conditions and perceptions of blame culture and organizational safety need to be explored before such processes can become entrenched in work flow., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Introduction: It has been suggested that doctors in their first year of post-graduate training make a disproportionate number of prescribing errors., Objective: This study aimed to compare the prevalence of prescribing errors made by first-year post-graduate doctors with that of errors by senior doctors and non-medical prescribers and to investigate the predictors of potentially serious prescribing errors., Methods: Pharmacists in 20 hospitals over 7 prospectively selected days collected data on the number of medication orders checked, the grade of prescriber and details of any prescribing errors. Logistic regression models (adjusted for clustering by hospital) identified factors predicting the likelihood of prescribing erroneously and the severity of prescribing errors., Results: Pharmacists reviewed 26,019 patients and 124,260 medication orders; 11,235 prescribing errors were detected in 10,986 orders. The mean error rate was 8.8 % (95 % confidence interval [CI] 8.6-9.1) errors per 100 medication orders. Rates of errors for all doctors in training were significantly higher than rates for medical consultants. Doctors who were 1 year (odds ratio [OR] 2.13; 95 % CI 1.80-2.52) or 2 years in training (OR 2.23; 95 % CI 1.89-2.65) were more than twice as likely to prescribe erroneously. Prescribing errors were 70 % (OR 1.70; 95 % CI 1.61-1.80) more likely to occur at the time of hospital admission than when medication orders were issued during the hospital stay. No significant differences in severity of error were observed between grades of prescriber. Potentially serious errors were more likely to be associated with prescriptions for parenteral administration, especially for cardiovascular or endocrine disorders., Conclusion: The problem of prescribing errors in hospitals is substantial and not solely a problem of the most junior medical prescribers, particularly for those errors most likely to cause significant patient harm. Interventions are needed to target these high-risk errors by all grades of staff and hence improve patient safety.

Introduction: The extent of preventable medication-related hospital admissions and medication-related issues in primary care is significant enough to justify developing decision support systems for medication safety surveillance. The prerequisite for such systems is defining a relevant set of medication safety-related indicators and understanding the influence of both patient and general practice characteristics on medication prescribing and monitoring., Objective: The aim of the study was to investigate the feasibility of linked primary and secondary care electronic health record data for surveillance of medication safety, examining not only prescribing but also monitoring, and associations with patient- and general practice-level characteristics., Methods: A cross-sectional study was conducted using linked records of patients served by one hospital and over 50 general practices in Salford, UK. Statistical analysis consisted of mixed-effects logistic models, relating prescribing safety indicators to potential determinants., Results: The overall prevalence (proportion of patients with at least one medication safety hazard) was 5.45 % for prescribing indicators and 7.65 % for monitoring indicators. Older patients and those on multiple medications were at higher risk of prescribing hazards, but at lower risk of missed monitoring. The odds of missed monitoring among all patients were 25 % less for males, 50 % less for patients in practices that provide general practitioner training, and threefold higher in practices serving the most deprived compared with the least deprived areas. Practices with more prescribing hazards did not tend to show more monitoring issues., Conclusions: Systematic collection, collation, and analysis of linked primary and secondary care records produce plausible and useful information about medication safety for a health system. Medication safety surveillance systems should pay close attention to patient age and polypharmacy with respect to both prescribing and monitoring failures; treat prescribing and monitoring as different statistical processes, rather than a combined measure of prescribing safety; and audit the socio-economic equity of missed monitoring.

Objectives: To investigate the underlying causes of intravenous medication administration errors (MAEs) in National Health Service (NHS) hospitals., Setting: Two NHS teaching hospitals in the North West of England., Participants: Twenty nurses working in a range of inpatient clinical environments were identified and recruited using purposive sampling at each study site., Primary Outcome Measures: Semistructured interviews were conducted with nurse participants using the critical incident technique, where they were asked to discuss perceived causes of intravenous MAEs that they had been directly involved with. Transcribed interviews were analysed using the Framework approach and emerging themes were categorised according to Reason's model of accident causation., Results: In total, 21 intravenous MAEs were discussed containing 23 individual active failures which included slips and lapses (n=11), mistakes (n=8) and deliberate violations of policy (n=4). Each active failure was associated with a range of error and violation provoking conditions. The working environment was implicated when nurses lacked healthcare team support and/or were exposed to a perceived increased workload during ward rounds, shift changes or emergencies. Nurses frequently reported that the quality of intravenous dose-checking activities was compromised due to high perceived workload and working relationships. Nurses described using approaches such as subconscious functioning and prioritising to manage their duties, which at times contributed to errors., Conclusions: Complex interactions between active and latent failures can lead to intravenous MAEs in hospitals. Future interventions may need to be multimodal in design in order to mitigate these risks and reduce the burden of intravenous MAEs., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background: Changes in the UK community pharmacy profession including new contractual frameworks, expansion of services, and increasing levels of workload have prompted concerns about rising levels of workplace stress and overload. This has implications for pharmacist health and well-being and the occurrence of errors that pose a risk to patient safety. Despite these concerns being voiced in the profession, few studies have explored work stress in the community pharmacy context., Objectives: To investigate work-related stress among UK community pharmacists and to explore its relationships with pharmacists' psychological and physical well-being, and the occurrence of self-reported dispensing errors and detection of prescribing errors., Method: A cross-sectional postal survey of a random sample of practicing community pharmacists (n = 903) used ASSET (A Shortened Stress Evaluation Tool) and questions relating to self-reported involvement in errors. Stress data were compared to general working population norms, and regressed on well-being and self-reported errors., Results: Analysis of the data revealed that pharmacists reported significantly higher levels of workplace stressors than the general working population, with concerns about work-life balance, the nature of the job, and work relationships being the most influential on health and well-being. Despite this, pharmacists were not found to report worse health than the general working population. Self-reported error involvement was linked to both high dispensing volume and being troubled by perceived overload (dispensing errors), and resources and communication (detection of prescribing errors)., Conclusions: This study contributes to the literature by benchmarking community pharmacists' health and well-being, and investigating sources of stress using a quantitative approach. A further important contribution to the literature is the identification of a quantitative link between high workload and self-reported dispensing errors., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Objective: To determine the prevalence, nature and predictors of prescribing errors (PEs) in three mental health hospitals., Setting: Inpatient units in three National Health Service (NHS) mental health hospitals in the North West of England., Participants: Trained clinical pharmacists prospectively recorded the number of PEs in newly written or omitted prescription items screened during their routine work on 10 data collection days. A multidisciplinary panel reviewed PE data using established methods to confirm (1) the presence of a PE, (2) the type of PE and (3) whether errors were clinically relevant and likely to cause harm., Primary Outcome Measures: Frequency, nature and predictors of PEs., Results: Of 4427 screened prescription items, 281 were found to have one or more PEs (error rate 6.3% (95% CI 5.6 to 7.1%)). Multivariate analysis revealed that specialty trainees (OR 1.23 (1.01 to 1.51)) and staff grade psychiatrists (OR 1.50 (1.05 to 2.13)) were more likely to make PEs when compared to foundation year (FY) one doctors, and that specialty trainees and consultant psychiatrists were twice as likely to make clinically relevant PEs (OR 2.61 (2.11 to 3.22) and 2.03 (1.66 to 2.50), respectively) compared to FY one staff. Prescription items screened during the prescription chart rewrite (OR 0.52 (0.33 to 0.82)) or at discharge (OR 0.87 (0.79 to 0.97)) were less likely to be associated with PEs than items assessed during inpatient stay, although they were more likely to be associated with clinically relevant PEs (OR 2.27 (1.72 to 2.99) and 4.23 (3.68 to 4.87), respectively). Prescription items screened at hospital admission were five times more likely (OR 5.39 (2.72 to 10.69)) to be associated with clinically relevant errors than those screened during patient stay., Conclusions: PEs may be more common in mental health hospitals than previously reported and important targets to minimise these errors have been identified., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Aims: Prescribing errors are common and can be detrimental to patient care and costly. Junior doctors are more likely than consultants to make a prescribing error, yet there is only limited research into the causes of errors. The aim of this study was to explore the causes of prescribing mistakes made by doctors in their first year post graduation., Methods: As part of the EQUIP study, interviews using the critical incident technique were carried out with 30 newly qualified doctors. Participants were asked to discuss in detail any prescribing errors they had made. Participants were purposely sampled across a range of medical schools (18) and hospitals (15). A constant comparison approach was taken to analysis and Reason's model of accident causation was used to present the data., Results: More than half the errors discussed were prescribing mistakes (errors due to the correct execution of an incorrect plan). Knowledge-based mistakes (KBMs) appeared to arise from poor knowledge of practical aspects of prescribing such as dosing, whereas rule-based mistakes (RBMs) resulted from inappropriate application of knowledge. Multiple error-producing and latent conditions were described by participants for RBMs and KBMs. Poor/absent senior support and a fear of appearing incompetent occurred with KBMs. Following erroneous routines or seniors' orders were major contributory factors in RBMs., Conclusions: Although individual factors such as knowledge and expertise played a role in prescribing mistakes, there were many perceived interrelated factors contributing to error. We conclude that multiple interventions are necessary to address these and further research is essential., (© 2014 The British Pharmacological Society.)

Background: There is a need to identify effective interventions to minimize the threat posed by medication administration errors (MAEs)., Objective: Our objective was to review and critically appraise interventions designed to reduce MAEs in the hospital setting., Data Sources: Ten electronic databases were searched between 1985 and November 2013., Methods: Randomized controlled trials (RCTs) and controlled trials (CTs) reporting rates of MAEs or related adverse drug events between an intervention group and a comparator group were included. Data from each study were independently extracted and assessed for potential risk of bias by two authors. Risk ratios (RRs, with 95 % confidence intervals [CIs]) were used to examine the effect of an intervention., Results: Six RCTs and seven CTs were included. Types of interventions clustered around four main themes: medication use technology (n = 4); nurse education and training (n = 3); changing practice in anesthesia (n = 2); and ward system changes (n = 4). Reductions in MAE rates were reported by five studies; these included automated drug dispensing (RR 0.72, 95 % CI 0.53-1.00), computerized physician order entry (RR 0.51, 95 % 0.40-0.66), barcode-assisted medication administration with electronic administration records (RR 0.71, 95 % CI 0.53-0.95), nursing education/training using simulation (RR 0.17, 95 % CI 0.08-0.38), and clinical pharmacist-led training (RR 0.76, 95 % CI 0.67-0.87). Increased or equivocal outcome rates were found for the remaining studies. Weaknesses in the internal or external validity were apparent for most included studies., Limitations: Theses and conference proceedings were excluded and data produced outside commercial publishing were not searched., Conclusions: There is emerging evidence of the impact of specific interventions to reduce MAEs in hospitals, which warrant further investigation using rigorous and standardized study designs. Theory-driven efforts to understand the underlying causes of MAEs may lead to more effective interventions in the future.

Background: Given the demanding nature of providing pharmacy services, coupled with the expanded scope of practice of the professions in jurisdictions around the world, greater commitment to continuous quality improvement through adoption of quality-related event (QRE) reporting is necessary to ensure patient safety. Pharmacy regulatory authorities (PRAs) are in a unique position to enhance QRE reporting and learning through the standardization of expected practice., Objective: This study was aimed to gain a better understanding of the perceived roles of PRAs in enhancing QRE reporting and learning in community pharmacies, and identifying regulatory best practices to execute such roles., Methods: A purposive case sampling approach was used to identify PRA staff members from two groups (Deputy registrars and pharmacy inspectors) in 10 Canadian jurisdictions to participate in focus groups in the fall of 2011. Focus groups were used to explore perceptions of the role of PRAs in enhancing and promoting QRE reporting and learning, and perceived barriers to effective implementation in practice. Thematic analysis was used to analyze the qualitative data., Results: Two focus groups were conducted, one with seven Deputy registrars/Practice managers, and one with nine pharmacy inspectors. Five themes were identified, including (1) defining QRE reporting and compliance, (2) navigating role conflict, (3) educating for enhanced QRE reporting and learning, (4) promoting the positive/removing the fear of QREs, and (5) tailoring QRE reporting and learning consistency., Conclusions: Overall, participants perceived a strong role for PRAs in enhancing QRE reporting and learning and providing education for pharmacies to support their compliance with reporting standards. However, PRAs must navigate the conflict inherent in both educating and promoting a process for achieving a standard while simultaneously inspecting compliance to that standard. Ensuring pharmacies have autonomy in operationalizing standards may help to mitigate this conflict. Finally, greater education for PRAs themselves to better inspect compliance and in order to better communicate the benefits of QRE reporting and learning to pharmacies would be beneficial., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: Underlying systems factors have been seen to be crucial contributors to the occurrence of medication errors. By understanding the causes of these errors, the most appropriate interventions can be designed and implemented to minimise their occurrence., Objective: This study aimed to systematically review and appraise empirical evidence relating to the causes of medication administration errors (MAEs) in hospital settings., Data Sources: Nine electronic databases (MEDLINE, EMBASE, International Pharmaceutical Abstracts, ASSIA, PsycINFO, British Nursing Index, CINAHL, Health Management Information Consortium and Social Science Citations Index) were searched between 1985 and May 2013., Study Selection: Inclusion and exclusion criteria were applied to identify eligible publications through title analysis followed by abstract and then full text examination. English language publications reporting empirical data on causes of MAEs were included. Reference lists of included articles and relevant review papers were hand searched for additional studies. Studies were excluded if they did not report data on specific MAEs, used accounts from individuals not directly involved in the MAE concerned or were presented as conference abstracts with insufficient detail., Data Appraisal and Synthesis Methods: A total of 54 unique studies were included. Causes of MAEs were categorised according to Reason's model of accident causation. Studies were assessed to determine relevance to the research question and how likely the results were to reflect the potential underlying causes of MAEs based on the method(s) used., Results: Slips and lapses were the most commonly reported unsafe acts, followed by knowledge-based mistakes and deliberate violations. Error-provoking conditions influencing administration errors included inadequate written communication (prescriptions, documentation, transcription), problems with medicines supply and storage (pharmacy dispensing errors and ward stock management), high perceived workload, problems with ward-based equipment (access, functionality), patient factors (availability, acuity), staff health status (fatigue, stress) and interruptions/distractions during drug administration. Few studies sought to determine the causes of intravenous MAEs. A number of latent pathway conditions were less well explored, including local working culture and high-level managerial decisions. Causes were often described superficially; this may be related to the use of quantitative surveys and observation methods in many studies, limited use of established error causation frameworks to analyse data and a predominant focus on issues other than the causes of MAEs among studies., Limitations: As only English language publications were included, some relevant studies may have been missed., Conclusions: Limited evidence from studies included in this systematic review suggests that MAEs are influenced by multiple systems factors, but if and how these arise and interconnect to lead to errors remains to be fully determined. Further research with a theoretical focus is needed to investigate the MAE causation pathway, with an emphasis on ensuring interventions designed to minimise MAEs target recognised underlying causes of errors to maximise their impact.

Objective: To systematically review empirical evidence on the prevalence and nature of medication administration errors (MAEs) in health care settings., Data Sources: Ten electronic databases (MEDLINE, EMBASE, International Pharmaceutical Abstracts, Scopus, Applied Social Sciences Index and Abstracts, PsycINFO, Cochrane Reviews and Trials, British Nursing Index, Cumulative Index to Nursing and Allied Health Literature, and Health Management Information Consortium) were searched (1985-May 2012)., Study Selection and Data Extraction: English-language publications reporting MAE data using the direct observation method were included, providing an error rate could be determined. Reference lists of all included articles were screened for additional studies., Data Synthesis: In all, 91 unique studies were included. The median error rate (interquartile range) was 19.6% (8.6-28.3%) of total opportunities for error including wrong-time errors and 8.0% (5.1-10.9%) without timing errors, when each dose could be considered only correct or incorrect. The median rate of error when more than 1 error could be counted per dose was 25.6% (20.8-41.7%) and 20.7% (9.7-30.3%), excluding wrong-time errors. A higher median MAE rate was observed for the intravenous route (53.3% excluding timing errors (IQR 26.6-57.9%)) compared to when all administration routes were studied (20.1%; 9.0-24.6%), where each dose could accumulate more than one error. Studies consistently reported wrong time, omission, and wrong dosage among the 3 most common MAE subtypes. Common medication groups associated with MAEs were those affecting nutrition and blood, gastrointestinal system, cardiovascular system, central nervous system, and antiinfectives. Medication administration error rates varied greatly as a product of differing medication error definitions, data collection methods, and settings of included studies. Although MAEs remained a common occurrence in health care settings throughout the time covered by this review, potential targets for intervention to minimize MAEs were identified., Conclusions: Future research should attend to the wide methodological inconsistencies between studies to gain a greater measure of comparability to help guide any forthcoming interventions.

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 different personal thresholds for reporting medication errors but pharmacists agreed that the severity of any patient harm was the primary reporting driver. Hospital pharmacists had specific anxieties about the effects of reporting on interprofessional working relationships with doctors and nurses, but felt more confident 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 find 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 effort required to use reporting forms., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Objective: To examine: (1) the reliability of the severity rating scale used by the National Reporting and Learning System (NRLS) in England and Wales for medication errors; and (2) the likelihood of reporting medication errors among healthcare professionals., Setting: A 900-bed acute university teaching hospital in the North West of England., Participants: Forty healthcare professionals (10 doctors, 10 nurses, 10 pharmacists and 10 pharmacy technicians)., Methods: Participants were asked to complete a self-administered questionnaire containing nine medication error scenarios on two separate occasions. They were asked to rate the severity of each incident using the NRLS severity rating scale and also the likelihood of reporting the incident via the hospital incident reporting system. The, Main Outcome Measures: included comparisons of severity ratings and likelihood of reporting by the four health professional groups. Test-retest reliability of the severity ratings was also examined within and between professional groups., Results: Pharmacists and nurses were significantly more likely to report the errors if they had witnessed them (mean scores 36.3 and 36.2, respectively, compared with 27.9 for doctors, P < 0.001). Nurses and pharmacy technicians assigned higher severity ratings for medication errors (mean scores 23.6 and 25, respectively) than pharmacists or doctors (both 19.4). Both within and between healthcare professional groups, there was wide variation in the assignment of medication error severity ratings., Conclusions: There are marked differences in the severity ratings for medication errors graded against the NRLS severity criteria between different health professional groups and at different time points rated by the same individuals.

Background: While much research has been conducted on medication safety, few of these studies have addressed primary care, despite the high volume of prescribing and dispensing of medicines that occurs in this setting. Those studies that have examined primary care dispensing emphasised the need to understand the role of sociotechnical factors (that is, the interactions between people, tasks, equipment and organisational structures) in promoting or preventing medication incidents. The aim of this study was to identify sociotechnical factors that community pharmacy staff encounter in practice, and suggest how these factors might impact on medication safety., Methods: Sixty-seven practitioners, working in the North West of England, took part in ten focus groups on risk management in community pharmacy. The data obtained from these groups was subjected to a qualitative analysis to identify recurrent themes pertaining to sociotechnical aspects of medication safety., Results: The findings indicated several characteristics of participants' work settings that were potentially related to medication safety. These were broadly classified as relationships involving the pharmacist, demands on the pharmacist and management and governance of pharmacists., Conclusion: It is recommended that the issues raised in this study be considered in future work examining medication safety in primary care.

Prescribing errors are common, they result in adverse events and harm to patients and it is unclear how best to prevent them because recommendations are more often based on surmized rather than empirically collected data. The aim of this systematic review was to identify all informative published evidence concerning the causes of and factors associated with prescribing errors in specialist and non-specialist hospitals, collate it, analyse it qualitatively and synthesize conclusions from it. Seven electronic databases were searched for articles published between 1985-July 2008. The reference lists of all informative studies were searched for additional citations. To be included, a study had to be of handwritten prescriptions for adult or child inpatients that reported empirically collected data on the causes of or factors associated with errors. Publications in languages other than English and studies that evaluated errors for only one disease, one route of administration or one type of prescribing error were excluded. Seventeen papers reporting 16 studies, selected from 1268 papers identified by the search, were included in the review. Studies from the US and the UK in university-affiliated hospitals predominated (10/16 [62%]). The definition of a prescribing error varied widely and the included studies were highly heterogeneous. Causes were grouped according to Reason's model of accident causation into active failures, error-provoking conditions and latent conditions. The active failure most frequently cited was a mistake due to inadequate knowledge of the drug or the patient. Skills-based slips and memory lapses were also common. Where error-provoking conditions were reported, there was at least one per error. These included lack of training or experience, fatigue, stress, high workload for the prescriber and inadequate communication between healthcare professionals. Latent conditions included reluctance to question senior colleagues and inadequate provision of training. Prescribing errors are often multifactorial, with several active failures and error-provoking conditions often acting together to cause them. In the face of such complexity, solutions addressing a single cause, such as lack of knowledge, are likely to have only limited benefit. Further rigorous study, seeking potential ways of reducing error, needs to be conducted. Multifactorial interventions across many parts of the system are likely to be required.

Prescribing errors affect patient safety throughout hospital practice. Previous reviews of studies have often targeted specific populations or settings, or did not adopt a systematic approach to reviewing the literature. Therefore, we set out to systematically review the prevalence, incidence and nature of prescribing errors in hospital inpatients. MEDLINE, EMBASE, CINAHL and International Pharmaceutical Abstracts (all from 1985 to October 2007) were searched for studies of prescriptions for adult or child hospital inpatients giving enough data to calculate an error rate. Electronic prescriptions and errors for single diseases, routes of administration or types of prescribing error were excluded, as were non-English language publications. Median error rate (interquartile range [IQR]) was 7% (2-14%) of medication orders, 52 (8-227) errors per 100 admissions and 24 (6-212) errors per 1000 patient days. Most studies (84%) were conducted in single hospitals and originated from the US or UK (72%). Most errors were intercepted and reported before they caused harm, although two studies reported adverse drug events. Errors were most common with antimicrobials and more common in adults (median 18% of orders [ten studies, IQR 7-25%]) than children (median 4% [six studies, IQR 2-17%]). Incorrect dosage was the most common error. Overall, it is clear that prescribing errors are a common occurrence, affecting 7% of medication orders, 2% of patient days and 50% of hospital admissions. However, the reported rates of prescribing errors varied greatly and this could be partly explained by variations in the definition of a prescribing error, the methods used to collect error data and the setting of the study. Furthermore, a lack of standardization between severity scales prevented any comparison of error severity across studies. Future research should address the wide disparity of data-collection methods and definitions that bedevils comparison of error rates or meta-analysis of different studies.

Objective: To examine the types of prescribing, administration and dispensing incidents reported to an on-line incident-reporting scheme and determine the types of healthcare professionals responsible for reporting such incidents., Method: Retrospective analysis of medication-related incidents reported to an on-line incident-reporting scheme in a large (1000-bed) teaching hospital in the UK., Main Outcome Measures: Frequency and type of incidents, the discipline of the health care professional who reported the incident and the stage in the medication use process (prescribing, dispensing, or administration) at which the incident occurred., Results: Over a 26-month study period, there were 495 medication-related incidents reported, of which 38.6% (191) were classified to be a "near miss". Medication-related incidents were reported most often at the stages of administration (230, 46.5%) and prescribing (192, 38.8%), whilst incidents involving dispensing or supply of medication were reported less often (73, 14.7%). Of all the incidents, pharmacists reported 51.9% (257), nursing staff reported 37.6% (186), and doctors reported 9.1% (45). Cardiovascular (149, 30.1%), central nervous system (106, 21.4%), and antibiotic/anti-infective medication (71, 14.3%) were the most common therapeutic categories associated with reports of medication-related incidents., Conclusion: An on-line reporting scheme can be used to monitor medication-related incidents at key stages in the medication-use process in secondary care. The types of incidents reported by health care professionals differ markedly, with fewer medication-related incidents being reported by doctors. Future research should explore the prevailing safety culture amongst the different health care disciplines, and examine the impact that information technology has on the willingness of health care professionals to report adverse incidents.

Background: In the UK the National Reporting and Learning System (NRLS) is designed to coordinate the reporting of patient safety incidents nationally and to improve the ability of the health service to learn from the analysis of these events. Little is known about levels of engagement with the NRLS., Objective: To examine the likelihood of community pharmacists and support staff reporting patient safety incidents which occur in community pharmacies., Methods: Questionnaire survey containing nine incident scenarios. In the scenarios two factors were orthogonally manipulated: the outcome for the patient was reported as 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 rate whether they would report the incident (1) locally within the pharmacy and (2) nationally to the National Patient Safety Agency (NPSA)., Results: 275 questionnaires were returned (79% response rate) from 223 community pharmacists and 52 members of support staff. 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. Both locally and nationally, the likelihood of reporting any incident was low, and judgements on whether to report were more affected by the behaviour of the pharmacist in relation to protocols than the resulting outcome for the patient., Conclusions: Community pharmacists and their support staff would be unlikely to report adverse incidents if they witnessed them occurring in a community pharmacy. They remain to be convinced that the advantages to them and their patients outweigh the consequences of blame.

Background: Each year over 600 million prescription items are dispensed in community pharmacies in England and Wales. Despite this, there is little published evidence relating to dispensing errors and near misses occurring in this setting. This study sought to determine their incidence, nature and causes., Methods: Prospective study over a 4-week period in 35 community pharmacies (9 independent pharmacies and 26 chain pharmacies) in the UK. Pharmacists recorded details of all incidents that occurred during the dispensing process, including information about: the stage at which the error was detected; who found the error; who made the error; type of error; reported cause of error and circumstances associated with the error., Results: 125,395 prescribed items were dispensed during the study period and 330 incidents were recorded relating to 310 prescriptions. 280 (84.8%) incidents were classified as a near miss (rate per 10,000 items dispensed=22.33, 95%CI 19.79-25.10), while the remaining 50 (15.2%) were classified as dispensing errors (rate per 10,000 items dispensed=3.99, 95%CI 2.96-5.26). Selection errors were the most common types of incidents (199, 60.3%), followed by labeling (109, 33.0%) and bagging errors (22, 6.6%). Most of the incidents were caused either by misreading the prescription (90, 24.5%), similar drug names (62, 16.8%), selecting the previous drug or dose from the patient's medication record on the pharmacy computer (42, 11.4%) or similar packaging (28, 7.6%)., Conclusions: This study has demonstrated that a wide range of medication errors occur in community pharmacies. On average, for every 10,000 items dispensed, there are around 22 near misses and four dispensing errors. Given the current plans for reporting adverse events in the NHS, greater insight into the likely incidence and nature of dispensing errors will be helpful in designing effective risk management strategies in primary care., (Copyright (c) 2004 John Wiley & Sons, Ltd.)