Likelihood of reporting adverse events in community pharmacy: an experimental study

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.

To examine the likelihood of community pharmacists and support staff reporting patient safety incidents which occur in community pharmacies.

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).

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.

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.