Understanding procedural violations and their implications for patient safety in community pharmacies

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Abstract

Background: Violations occur when individuals choose to bypass or deviate from procedures. Although violations are often not intended to cause harm, they are nevertheless breaches of the preferred way of working. Violations have been suggested to introduce risk into the environment by eroding the margin of safety. Therefore, violations are of potential concern to healthcare professionals that are responsible for patient safety. This thesis examines how and why violations occur in community pharmacies. Method: The research adopted a mixed methods approach to explore violations in community pharmacies and three studies were undertaken. The first study was a qualitative study that explored the views of management and frontline staff with regards to the prevailing safety culture in community pharmacies. The aim was to understand the context in which violations occur and to explore the goals that staff manage in practice. The second interview study explored how procedures are perceived in practice and the types of violations that occur in this setting. The third study utilised a survey based on the COM-B model that further explored the influence of capability, opportunity and motivation on violating behaviours. Results: Overall, findings demonstrated that numerous types of violations occur in community pharmacies. Mainly they occur either to ensure that timely patient care is provided or to ensure that productivity is maintained in practice. The safety culture study suggested that frontline staff and management have a different safety culture, with frontline staff reacting to risk in the moment and head office staff managing risk through the provision of multiple detailed procedures. The interviews suggested that procedures are useful for outlining what is expected of staff in practice; however they are not always possible to follow to the letter due to the complex working environment. The social norm within each pharmacy was suggested to influence violating behaviours, as was the professional judgement of the pharmacist. Violations were shown to be necessary for maintaining care at times, especially in exceptional circumstances. However, at times violations to maintain productivity did result in an increased risk to patient safety. The questionnaire study highlighted motivation, opportunity, length of experience, staff role and gender as influences on certain types of violations. Conclusions: The mixed methods utilised as part of this thesis revealed the types of violations that occur in community pharmacies and the reasons why pharmacists and support staff choose to violate. The findings led to recommendations for policymakers to evaluate how procedures are implemented in practice, to provide additional support for staff in practice through improved workflow, to provide patient safety specific training in pharmacies, to improve communication between frontline and head office staff and to educate pharmacy students regarding the possibility that they will need to violate procedures at times to manage the complex reality of working within community pharmacies.

Keyword(s)

Patient safety; Pharmacy; Psychology; Violations

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