Exploratory research in clinical and social pharmacy · 2026
Factors contributing to medication safety incidents observed by community pharmacists - a content analysis of incident reports.
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Lohtaja Milka, Schoultz Anna, Mönkkönen Iina, Holmström Anna-Riia
Аннотация
BACKGROUND: Medication errors pose a risk to outpatient medication safety. Community pharmacists play a central role in medication safety; however, their contribution to risk management in social and healthcare settings is less studied.
OBJECTIVES: This study aims to explore factors identified by community pharmacists contributing to medication errors originating outside pharmacies. It aims to show how community pharmacies can collaborate with social and healthcare organisations to enhance medication safety.
METHODS: Medication safety incident reports from three wellbeing services counties in Finland were analysed using qualitative content analysis. A data-driven approach with the Systems Engineering Initiative for Patient Safety (SEIPS) model was applied to categorise and quantify contributing factors in incident reports.
RESULTS: All detected incidents (n = 461) concerned prescribing errors, with contributing factors identified in 80% (n = 367/461). Altogether, contributing factors were identified 573 times in the incident reports. Organisational factors were the most common, constituting deficiencies in written communication (14%, n = 81/573) and in work environment and management (13%, n = 76/573). These were followed by task-related factors comprising deficiencies in working methods (15%, n = 88/573), and person-related factors, (e.g., lack of knowledge and skills) (8%, n = 48/573). The least emerging factors were related to physical environment (<1%, n = 1/573), technical problems in prescription writing (1%, n = 6/573), and packaging or features of medicinal products (2%, n = 11/573).
CONCLUSION: Community pharmacists were able to identify factors behind prescribing errors from other social and healthcare organisations. Their insights can help improve prescribing processes and medication safety, supporting the value of inter-organisational collaboration, though further research and standardised reporting are needed.
OBJECTIVES: This study aims to explore factors identified by community pharmacists contributing to medication errors originating outside pharmacies. It aims to show how community pharmacies can collaborate with social and healthcare organisations to enhance medication safety.
METHODS: Medication safety incident reports from three wellbeing services counties in Finland were analysed using qualitative content analysis. A data-driven approach with the Systems Engineering Initiative for Patient Safety (SEIPS) model was applied to categorise and quantify contributing factors in incident reports.
RESULTS: All detected incidents (n = 461) concerned prescribing errors, with contributing factors identified in 80% (n = 367/461). Altogether, contributing factors were identified 573 times in the incident reports. Organisational factors were the most common, constituting deficiencies in written communication (14%, n = 81/573) and in work environment and management (13%, n = 76/573). These were followed by task-related factors comprising deficiencies in working methods (15%, n = 88/573), and person-related factors, (e.g., lack of knowledge and skills) (8%, n = 48/573). The least emerging factors were related to physical environment (<1%, n = 1/573), technical problems in prescription writing (1%, n = 6/573), and packaging or features of medicinal products (2%, n = 11/573).
CONCLUSION: Community pharmacists were able to identify factors behind prescribing errors from other social and healthcare organisations. Their insights can help improve prescribing processes and medication safety, supporting the value of inter-organisational collaboration, though further research and standardised reporting are needed.