Table 5.

Themes, categories, codes and quotes to understand the contradiction of the increase of medication incident reports and the reduction in medication safety risks

Theme	Category	Codes	Representive Quotes
I. Activities designed to improve medication safety	Improvements made based on the IGZ visits	Reducing emergency supply of medication; agreement with pharmacy; constructing medication working groups; agreements managing and administering medication; double-checks; training; ‘do not disturb’ logo; electronic prescribing; transition to another pharmacy; reformulating protocols	‘We formed a medication working group, with a board member as chairman, with different kinds of care professionals.’ (interviewee 10, care manager) ‘The agreements with the pharmacists on monitoring medication safety and both their responsibility, and that of the organisation itself were reformulated over time.’ (interviewee 10, care manager) We received medication from several community-based pharmacies. We were not at all happy with that. In the end, we went along with one party.’ (interviewee 3, medical director)
	Improvements made based on the organisation taking its own initiative	Internal audit; form a commission for incident reports; consultation of pharmacist and general practitioner; agreement with pharmacy; (reformulating) guideline reporting incidents; constructing medication working groups; electronic prescribing; ‘do not disturb’ logo; regular training; double-checks	‘One of our focus points was to introduce the double check on medication and ‘do not disturb’ logos during distribution.’ (interviewee 8, policy maker) ‘We use coloured jackets with a ‘do not disturb’ logo while distributing medication. However, psycho geriatric patients may not understand the meaning of the jackets, and sometimes ignored them, which can be difficult.’ (interviewee 5, location manager)
	Improvements made through collaboration with third parties	Referring to guidelines and protocols; agreement with pharmacy; consultation of another care facility/location, professional association, knowledge centre, general practitioner, pharmacy	‘Furthermore, we consulted pharmacists and reported on, for example, prescribing behaviour. Based on this information, we reviewed critically protocols for distribution.’ (interviewee 3, medical director)
II. Reporting of medication incidents	The internal causes of increased reports	Willingness; safe culture; clear what to report; automatic behaviour; no fear; lower threshold	‘It has become automatic. Employees do not have to worry that they might get punished if they report an incident. Previously, that feeling prevailed. That implies we had to reduce the fear of reporting and to make it clear that it is just an instrument to improve quality.’ (interviewee 7, care manager) ‘The barrier to report incidents was reduced. We saw an abrupt increase in reported errors. But if improvements are achieved and the quality and safety of medication is guaranteed, then we will notice that it actually contributes to reducing errors.’ (interviewee 4, policy advisor)
	The internal causes of fewer reports	Automated medication dispensing system; simplified processes; raised awareness; training; ‘do not disturb’ logo; managing medication per patient; verbal report	‘We organized training for professionals, to, among other things, stimulate their awareness about medication safety.’ (interviewee 1, medical director) ‘A lot of medication was forgotten, and was not administered or prepared well. By using the automated medication dispensing system, quite a lot of these errors were prevented.’ (interviewee 6, nurse)
	The national causes of increased reports	Raised awareness; small incidents are reported; digitisation of reporting; higher complexity of processes; workload; more complexity of care; taboo -subject is broken	‘The amount of medication incident reports used to be very low. But we could not say that nothing was wrong. We especially concluded: employees did not report errors. We realised that we had to stimulate that they would report.’ (interviewee 10, care manager)
III. Impact of supervision	The effects of the IGZ visits	Focus on details; speeds improvement processes; stimulates collaboration; raises awareness; objective judgment; catalyst; makes funding available	‘The visits of the Health Care Inspectorate causes alarm bells to ring.’ (interviewee 4, policy advisor) ‘It accelerates the process and made our medication process very accurate.’ (interviewee 1, medical director) ‘Also it matters to the board whether the Health Care Inspectorate indicates improvement is necessary. It opens doors or makes investments possible. Therefore, as professionals, we sometimes ‘used’ the Inspectorates’ authority to make necessary changes which we weren’t able to establish ourselves, unfortunately.’ (interviewee 2, pharmacist, responsible for medication care in nursing homes)
	The lack of effect of the IGZ visits	Intrinsic motivation; critical employees; good internal working environment	‘Honestly, I think that most of the improvements came from ourselves. We wanted things to get better, so we took care that things were getting better.’ (interviewee 3, medical director) ‘Did the Inspectorate have any influence on the willingness to report incidents? I don’t think so. It is merely an internal development, concerning how to deal with each other, what is the management style, how do employees experience reporting? So I think it is above all an internal matter. I don’t think the visits or the report of the IGZ contributed to that change of culture.’ (interviewee 10, care manager)