Table 3.
List of all included studies in review
| Article | Country | Year | Medication safety focus | Role of culture |
|---|---|---|---|---|
| Aarts [70] | The Netherlands | 2013 | Prescribing | Prescribing is a social act which shows the authority of the doctor in being able to ‘solve’ the patient’s problem. Electronic prescribing challenges embedded social norms attached to professions. The author argues that interventions should take into account cultural nuances that may exist |
| Aboshaiqah [83] | Saudi Arabia | 2013 | Medication error reporting | Administrative response to error and fear was an important barrier to nurses in reporting medication administration errors. Staff believed there was too much emphasis placed upon errors as a marker of quality of care and errors weren’t looked upon from the perspective of the system-only the individual |
| Alqubaisi et al. [44] | United Arab Emirates | 2016 | Medication error reporting | Nurses and pharmacists’ likelihood to report errors was impacted by the perceived professional hierarchy and ‘power’ of doctors-with doctors wanting less formal platforms for errors to be discussed (i.e. a conversation). Pharmacists, doctors and nurses elicited a fear of reporting-worrying it would impact their reputation or result in litigation. Nurses elicited a greater fear of litigation |
| Andersen [84] | Denmark | 2001 | Prescribing | Professional culture as a barrier to collaborative working. The authors report that nurses and doctors had strong professional identities and when implementing a new drugs record system, the intervention challenged established roles of nurses and doctors. The authors characterized nurses by collectivism, whereas the doctors were more competitive and individualistic |
| Boyle et al. [55] | Canada | 2011 | Medication error reporting | Supportive organizational culture, defined as ‘enthusiasm about improved reporting … creating a safe reporting environment,’ was found to be an significant variable in ensuring reporting of medication safety incidents |
| Chiang et al. [85] | Taiwan | 2010 | Medication error reporting | Failure to report was strongly influenced by nurses’ experience of making medication administration errors. Barriers to reporting included fear, perception of nursing quality and perception of nursing professional development |
| Debono et al. [69] | Australia | 2013 | Compliance with protocols | There are deviations of medication safety practices across areas—for example, not checking identification bands in long term wards, as the staff are familiar with the patients |
| Dickinson et al. [68] | USA | 2012 | Safe Medicines Administration | Norms are passed on within professions and role modelling of these norms by professionals ensure they become common practice |
| Dolansky et al. [60] | USA | 2013 | Reducing medication errors/investigation into errors | Case study of a medication error. Looking at the error from an organizational and professional lens, the study identified that the unit level’s response to an error is important, as well as communication between nurses and senior staff |
| Federwisch et al. [86] | USA | 2014 | Interventions | This study, an evaluation of an intervention to reduce interruptions to nurses during their drug rounds, found that nurses elicited that the signs (to not interrupt) were not respected. The vests worn by nurses were poorly received, with the authors postulating that the ‘vests signify unavailability which didn’t mesh well with a nursing culture that values flexibility and availability’ |
| Flanders and Clark [49] | USA | 2010 | Reducing medication errors/investigation into errors | Interventions aiming to limit interruptions to nurses during their drug rounds were fraught with difficulties because they implicitly challenged a nursing culture that pride themselves on availability and ability to multitask |
| Furmedge and Burrage [71] | UK | 2012 | Prescribing | Doctors arrived with limited knowledge of prescribing, however the authors argue that due to exposure to other colleagues within the profession, bad habits flourish which become difficult to ‘stamp out’ |
| Gill et al. [66] | Australia | 2012 | Compliance with protocols | Medication related practices became routine practices by ‘the nursing gaze’—a term coined by the authors which was defined as a ‘surveillance strategy by which nurses examined each other’s activities.’ ‘Ward culture’ was important, where some areas were more diligent than others in complying with protocols. Junior nurses were discouraged from following protocols (e.g. checking ID bands) by their senior colleagues-with the authors concluding negative role modelling and active discouragement were key influences on practices being reinforced |
| Gimenes et al. [57] | Brazil | 2016 | Safe Medicines Administration | Trust and cooperation among staff in an intensive care unit influenced medication safety culture. On a wider organizational level, the trust had a zero tolerance to errors and the frequent firing strengthened a culture of punishment. There was a focus on the person making the error, rather than improving processes. On a professional level, nurses believed pharmacists didn’t understand their day-to-day difficulties and there was a lack of communication |
| Hammoudi et al. [58] | Saudi Arabia | 2018 | Medication error reporting | Medication errors were influenced by the communication process between nurses and doctors, and the reporting of these errors was influenced by nurses’ fear of reporting, and the administration response to the error—for example, a nurse being individually blamed for the error |
| Hartnell et al. [43] | Canada | 2012 | Medication error reporting | Professionals reported a fear that reporting an error would threaten their professional identity by appearing incompetent to colleagues. Organizational barriers, or ‘how things are done around here,’ resulted in an ineffective reporting system and no learning from errors |
| Hawkins et al. [63] | USA | 2017 | Systems evaluation | Pharmacists were an important ‘stop-gap’ between errors getting to the patient, however the authors reported that the pharmacists did not formally supporting the reporting of these errors. There were examples of interventions taken by the pharmacist to correct doctors’ errors but there were no examples of pharmacists informing the doctors of their error. This lead the authors to conclude that inter-professional hierarchies remain an issue within medication safety |
| Hemphill [56] | USA | 2015 | Interventions | The authors argue that while organizations may feel punitive responses to error are justified; it will not serve to be useful in understanding the processes and systems that contributed to the error. They claim that leadership is the ‘driving force’ behind a safety culture, where frontline staff will only believe safety is important if their senior leaders encourage this |
| Hong and Li [38] | China | 2017 | Medication error reporting | Safety climate was the most important domain impacting a unit’s safety culture. Nurses considered the unit’s overall safety culture as influential in reporting adverse events—where a flexible organizational culture promoted patient safety and reporting of adverse events due to instilling trust among the nurses |
| Hughes and Ortiz [52] | USA | 2005 | Reducing medication errors/investigation into errors | Clinicians have preconceptions about patient safety more generally which impacts their likelihood to engage in reporting and learning from errors. The authors comment that common feelings attached to reporting error are fear of being blamed, fear of litigation or serious impacts to the individual’s career |
| Hughes et al. [87] | UK | 2007 | Prescribing | Patterns of prescribing represent the visible artefacts of organization members but greater focus should be placed upon how these cultural patterns are created, communicated and maintained |
| Jacobs et al. [46] | Manchester, UK | 2011 | Medicines reconciliation/advanced pharmacy | There is a range of evidence describing aspects of organizational culture and its impact upon community pharmacy without explicitly defining this as organizational culture in this context. Authors identified five dimensions of organizational culture: the professional-business role dichotomy; workload, management style, social support and autonomy; professional culture; attitudes to change and innovation; and entrepreneurial orientation |
| Janmano et al. [62] | Thailand | 2018 | Medication error reporting | In a social network analysis of reporting medication errors, pharmacists were found to be central in the network of consultation on medication and were discussed to be ‘bridges’ between nurses and doctors |
| Kagan and Barnoy [35] | Israel | 2013 | Medication error reporting | The correlation between patient safety culture at an organizational level and error reporting rate was significant, leaving the authors to deduce that the ‘better’ the organizational culture for patient safety was, the more likely nurses were to report errors |
| Kavanagh [50] | Republic of Ireland | 2017 | Reducing medication errors/investigation into errors | Discusses the role of medication incidents on nurses-identifying that they feel guilt or too heavily bear the blame, leaving them to feel incompetent. There is a need for a blame free culture which can empower staff to report, with the authors arguing that this will have a significant impact on whether or not errors are noticed and reported |
| Kaissi et al. [64] | USA | 2007 | Reducing medication errors/investigation into errors | The use of practice guidelines was associated with reduced medication error rates in groups with a more ‘collegial’ culture-defined as a culture fostering coordination within doctors and between nurses and doctors |
| Kelly et al. [67] | USA | 2016 | Interventions | This article discusses the role of workarounds which can serve as a barrier to successful implementation of an intervention. These solutions, implemented by the nurses as solutions to their everyday issues, were found to be deeply ingrained into practice-so instead of being seen as workarounds or hazards to the staff, they are common and accepted practice |
| Liu et al. [61] | Australia | 2011 | Medication error reporting | Communication is influenced by hierarchy that exists in organizations and relates generally to vertical hierarchies, resulting in role conflict and struggles with interpersonal power and relationships |
| McBride-Henry and Foureur [88] | New Zealand | 2006 | Safe Medicines Administration | Staff nurses did not feel that senior leaders in their hospitals listened to their concerns and at times, nurses believed that they felt powerless to address the medication safety incidents they identified because it was beyond the scope of their position. Communication across the multi-disciplinary team was seen as important to nurses |
| Moody [48] | USA | 2006 | Medication error reporting | On the behavioural motivation scale, items involving worry, fear, anger and criticism relative to medication errors were scored highly by nurses. Nurses felt that the authority gradient in their organization hindered their ability to confidently engage and ask questions with someone of ‘higher’ authority. 2/3 of nurses described themselves as ‘prudent’ when dealing with authority and would only speak up if they deemed themselves to have ‘proper’ authority. Across different organizations, significant differences in nurses’ perceptions of their safety culture relative to different managers and supervisors |
| Ramsay et al. [22] | UK | 2014 | Compliance with protocols | Nurses were more engaged with medication score-card feedback than doctors, which identified contrasting approaches to improvement in the two professions. Nurses reported being more likely to be removed from their responsibilities if a drug error happened. Examples of ‘normalised deviance’ where errors were seen to be normal or unsurprising across areas and professions |
| Reid-Searl and Happell [59] | Australia | 2011 | Safe Medicines Administration | Participants of the study referred to the culture of the specific units and hospitals and claimed this had an important influence on the way they administered drugs and discussed the need to ‘fit in’ to the environment |
| Sahay et al. [53] | Australia | 2015 | Medication error reporting | Graduate nurses reported feeling reluctant to approach nursing colleagues for advice on medication administration. Graduate nurses experienced condescending language and felt nurses were impatient with their questions. Nurses also identified they felt blamed for medication errors that were made by doctors or other nurses |
| Salem et al. [51] | UK | 2013 | Medication error reporting | There was an organization-wide apathy to reporting as respondents elicited it was unlikely to respond with any meaningful feedback or change. Junior staff reported anxiety in challenging their more ‘superior’ colleagues. The authors identified that reporting errors was influenced by a feeling of protecting oneself and subsequent obligation. Respondents found that the response to an error by a nurse was more of an ‘open book,’ but when a doctor made a mistake it was ‘kept quiet’ with no learning of what happened as a result |
| Samsuri et al. [36] | Malaysia | 2015 | Medication error reporting | Pharmacists working in health clinics were 3.7 times more likely to have positive overall safety culture scores compared to pharmacists working in the hospitals. Reporting practices were impacted by the overall safety culture |
| Sarvadikar and Williams [45] | UK | 2009 | Medication error reporting | Nurses, doctors and pharmacists felt criticism and blame would follow if they reported an error. Nurses showed a greater fear of disciplinary action or even losing their jobs after an error compared to pharmacists and doctors. Nurses and pharmacists indicated they would report all errors irrespective of the patient outcome, whereas doctors were more likely to report the error if the patient’s condition worsened |
| Smetzer et al. [54] | USA | 2003 | Safe Medicines Administration | Hospitals that elicited a non-punitive approach to error reductions were more likely to be better at detecting, reporting and analysing errors. There were strong correlations between a strong supportive culture and the reporting of errors |
| Smits et al. [89] | The Netherlands | 2012 | Reducing medication errors/investigation into errors | In the same hospital, surgical and medical units were more likely to report errors compared to the emergency department. Non-punitive response to error, hospital management support and willingness to report were influenced by the overall safety culture in the units |
| Tricarico et al. [90] | Italy | 2017 | Medication error reporting | Incident reporting rates by profession were analysed prospectively and saw an increase of doctors engaging with reporting. The authors state that doctors started with initial scepticism before increasing involvement and reporting practices and that the incident reporting system was nor fully accepted by their own professional improvement ideologies |
| Turner et al. [23] | UK | 2013 | Medicines reconciliation/advanced pharmacy | Attitudes towards medication safety varied across professions-with pharmacists believing it was central to their hospital socialization. Attitudes were shaped by the social norms practices within the specialities and therefore awareness of medication safety practices differed across different specialties. Nurses elicited a higher likelihood to report errors due to their fear of litigation |
| Vogus and Sutcliffe [91] | USA | 2001 | Medication error reporting | Units within hospitals exhibit significant variation in safety organization and perceived trust in leadership. Unit-level leaders are able to enhance the effects of safety organizing on patient safety by fostering trust, thus making clinicians feel safe to discuss near-misses and errors |
| Wakefield et al. [37] | USA | 2011 | Medication error reporting | Explored role between four culture types, group-type culture, development-type culture, hierarchical-type culture and rational-type culture and reasons why medication administration errors were not reported. A hierarchical or rational-type culture was negatively associated with reporting of medication administration errors |