Reporting on AEs and Promoting a Safety Culture

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In the decision to be active in reporting medication errors, attitudinal components can play a role. When examining trends and issues such as these, we need to look toward initial attitudinal research and other descriptive data that helps us to explain the phenomenon. Then we hope for actions, interventions, and research that has taken place to leverage that initial descriptive research that has provided a way forward for clinicians in their practice.

Gleeson et al conducted a systematic review of interventions aimed at improving pharmacists’ reporting of adverse medication events.1 Types of interventions included critical incident reporting, audit and feedback, educational materials, educational meetings, role expansion, and task-shifting. Unfortunately, very few of the studies used a control and intervention group, and the review authors could not discern a comparative effectiveness between the interventions without proper evidence. More contemporary strategies include the use of mobile telephone applications for medication event reporting, and these have demonstrated initial promise. The review also uncovered the challenge of finding computer systems isolated enough and not otherwise used for other purposes so as to ensure privacy and continuity. Yet this review also observed the challenges one might expect (logistics, time) to implement paper-based systems. Qualitative studies confirmed pharmacists’ fear of reporting due to an organizational culture that does not promote doing so. Likewise, other studies highlighted the importance of anonymity in reporting.

Pharmacy managers must promote a culture of patient safety. Doing so is borne from a societal mandate. However, an organization that only pays lip service to such a culture and instead seems more preoccupied with finding fault and exacting retribution for mistakes will discourage adverse event reporting, even those that had nothing to do with human error. Furthermore, managers must identify tools, software, and mechanisms to best facilitate reporting and promote safety. Until we find evidence otherwise, a one-size-fits-all approach does not appear appropriate. This might be a blessing in disguise, as each pharmacy manager can exercise autonomy in implementing systems and resources that best meet the needs of their organization.

Additional information about Ensuring Quality in Pharmacy Operations and Preventing and Managing Medication Errors: The Pharmacist’s Role can be found in Pharmacy Management: Essentials for All Practice Settings, 5e. If you or your institution subscribes to AccessPharmacy, use or create your MyAccess Profile to sign-in to Pharmacy Management: Essentials for All Practice Settings, 5e. If your institution does not provide access, ask your medical librarian about subscribing.

1Gleeson L, Dalton K, O’Mahoney D, Byrne S. Implementations to improve medication error reporting in hospitals: A systematic review and narrative synthesis. Res Social Adm Pharm. 2020; https://doi.org/10.1016/j.sapharm.2019.12.005.

Shane Desselle

Professor of Social and Behavioral Pharmacy, Touro University California

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Shane Desselle 6 months ago

Does your organization’s culture promote patient first and safety, or does it promote fear?