Knowledge and Attitude toward Medication Error among Pharmacists

Abstract

Objective: This study aimed to evaluate knowledge and attitude toward medication error (ME) among pharmacists working in public health care institutions. Methods: A cross-sectional study was conducted among pharmacists working in public health care institutions. Respondents were randomly recruited from 5 hospitals and 25 primary healthcare clinics in the state of Pahang, Malaysia. A set of self-administered questionnaires was used to assess their knowledge and attitude, distributed as a web-based survey. Knowledge and attitude toward ME reporting were assessed using five-point Likert-scale. This study was conducted between May and July 2019. Results: A total of 186 respondents participated in the study. A majority of respondents were female (n = 144). About 90% of the respondents had good score on knowledge on ME. Only 25.4% of the respondents had favorable attitude toward ME reporting. Female pharmacists (P = .001), more experienced pharmacists (P = .012) and those working in primary health clinics (P = .014) were associated with more favorable attitude. Knowledge did not correlate well with attitude toward ME reporting (r = 0.08, P = .29). Conclusion: Despite having good knowledge on ME, the attitude toward ME reporting was still very poor among the pharmacists.

Introduction

Patient safety has always been the focus for every healthcare provider in ensuring quality health care delivery. The increasing use of technology and the involvement of many types of health professionals providing care have resulted in a complex system of health care delivery. In 2017, the World Health Organization (WHO) launched the “Medication without Harm” campaign as a global initiative to improve patient safety by strengthening the health care systems for reducing medication errors. ¹ Medication error can occur at any stage of the medication-use process. Thus, it is imperative that countries take action to address and improve the medication-use practice by healthcare professionals.

Many countries have put in place their own approaches to address safety issues that may contribute to medication errors, including intervention strategies and reporting programs. In the USA, various reporting programs are available including the Food and Drug Administration’s (FDA) MedWatch Reporting Program, the United States Pharmacopeia-Institute for Safe Medication Practices’ (USP-ISMP) Medication Errors Reporting Program, and the MedMarx® Reporting Program. ² Across European Union (EU) member states, the European Medicines Agency (EMA) coordinates the EU pharmacovigilance network. Medication errors are reported through national pharmacovigilance systems as well as to EudraVigilance, the EU database for adverse reactions. ³ In developing countries like the Middle East, there are variations in the implementation and activities of pharmacovigilance systems. ⁴ Data regarding medication error reporting are mostly from hospital and primary care studies. ⁵ Similarly, most Southeast Asian countries have their own pharmacovigilance systems. However, medication error reporting and documentation in these countries are still inadequate. ⁶

Malaysia spent about MYR2.4 billion (1USD – MYR4.3) for medicine expenditure in 2017 and approved about 20 new formulations annually. ⁷ While the number of inpatient prescriptions in government hospitals average around 21 million per year, outpatient prescriptions have seen a steady increase over the years, reaching almost 60 million prescriptions in 2017. ⁸ With increasing number of prescriptions nationwide, one would therefore expect an increase in medication-related events as well. In fact, Samsiah et al ⁹ have shown that medication errors reported to the National Medication Error Reporting System (NMERS) increased over the years from 2626 reports in 2009 to 5770 reports in 2012. These data were based on the paper-reporting system. An online reporting system was launched toward the end of 2012. Likewise, data from the online system also showed an increasing trend in medication error reports and by 2016, a total of about 20 000 medication errors were received through the NMERS online system. ⁷ At the same time, data from the Malaysian Adverse Drug Reaction Advisory Committee (MADRAC) also show an increasing trend in reports of ADR received by the national monitoring center. ¹⁰ The trends may actually reflect an actual increase in those medication-related events or it could also be due to increased awareness to reporting among healthcare professionals.

Despite the increase in trends of ME reporting, many have shown that ME is still underreported in actual practice.^11,12 In addition, findings from Samsiah et al ⁹ showed that not all public health institutions in this country participated actively in ME reporting. Only a few institutions have been consistently contributing to the reporting activities. Therefore, in this study we aimed to evaluate the knowledge on perceived causes of ME and attitude toward ME reporting among pharmacists working in public hospitals and health clinics, and to determine whether knowledge is associated with attitude toward ME reporting.

Materials and Methods

Study Design, Respondent and Location Background

A cross-sectional study was conducted by utilizing a set of self-administered questionnaires, distributed as a web-based survey among pharmacists in the state of Pahang, Malaysia between May 2019 and July 2019. This study utilized the questionnaire, which has been previously developed and validated. ⁸

Sample Size and Sampling

The state of Pahang has approximately 1.6 million populations. It has a network of 7 hospitals and 76 primary healthcare clinics managed by the Ministry of Health. ⁷ At the time of the study, there were about 500 pharmacists working in these public healthcare facilities. Those facilities and pharmacists (n = 200) previously involved in the questionnaire validation phase were excluded. Pharmacists who were working as enforcement officers (n = 30), and in the administrative section (n = 10), were also excluded from this study.

Sample size was estimated using Raosoft sample size calculator (www.raosoft.com) with alpha value of 0.05 and the confidence interval at 95%. After taking into consideration possible non-respondents and missing data (20%), the final sample size was determined to be 223. We first stratified our pharmacist population by healthcare facilities. Pharmacists were recruited from pharmacy departments of these healthcare facilities using stratified random sampling technique.

Study Instruments and Data Collection

All pharmacists were ensured anonymity and confidentiality. The questionnaire has been shown to demonstrate good psychometric properties. ¹³ It consisted of 3 parts (i) socio-demographic characteristics (eg, gender, current age, working experience, work setting and education level), (ii) knowledge on ME, and (iii) attitude toward ME reporting.

Knowledge and attitude toward ME reporting were assessed using five-point Likert-scale ranging from “strongly agree” to “strongly disagree”. Data was collected using a web-based survey at www.surveymonkey.com. Pharmacists were required to provide informed consent by clicking the radio button/check box before proceeding with the survey. The link for the survey was emailed to selected pharmacists. A second reminder was sent 2 weeks from the first email and a third reminder followed 2 weeks later. The link of the survey was closed after the allocated time frame.

Data Analysis

Data were analyzed using Statistical Package for the Social Science (SPSS) version 23.0. Descriptive statistics was applied, and results were presented as frequency (%) for categorical data and mean (standard deviation) for numerical data. Differences in total scores among demographic groupings were tested using Mann–Whitney U test. Spearman correlation test was used to assess the relationship between knowledge and attitude toward ME reporting. P-values <.05 were considered statistically significant.

Results

Socio-Demographic Characteristics

Out of 223 pharmacists recruited in this survey, 186 pharmacists (83.4%) responded within the allocated time frame. The majority of respondents were female (n = 144, 77.4%). The respondents mean age was 30.7 years (SD = 3.49) and 81% of them had less than 8 years working experience (Table 1).

Table 1.

Socio-Demographic Characteristics of Respondents (N = 186).

Variable	Mean (±SD)	n (%)
Gender
Male		42 (22.6)
Female		144 (77.4)
Age (years)	30.7 (3.49)
Highest education
Undergraduate		179 (96.2)
Postgraduate (Master)		7 (3.8)
Work setting
Hospital		93 (50)
Primary health centers		93 (50)
Working experience
<8 y		150 (80.6)
≥8 y		36 (19.4)

Knowledge on ME and Attitude toward ME Reporting

About 90% of the respondents had good score on knowledge of ME. The top 5 perceived causes of ME chosen by more than 90% of respondents were confusion between similar drug names (97.3%), filling the wrong drug (96.7%), wrong dose calculation (95.7%), illegible prescription (92.4%) and failure to ensure right patient getting the right drug (91.9%). (Table 2). For the domain on attitude toward ME reporting, about 45% of respondents had poor attitude. Many respondents (76.3%) agreed that they did not report ME for afraid of being fired (Table 3).

Table 2.

Knowledge on ME (N = 186).

	Strongly agree	Agree	Neutral	Disagree	Strongly disagree	Mean score (±SD)
Knowledge	n (%)
ME occurs when pharmacist fails to ensure the right patient receiving the right drugs with right dose and quantity	90 (48.4)	81 (43.5)	8 (4.3)	6 (3.2)	1 (0.5)	1.64 (0.76)
ME occurs when physician’s writing on the prescription is difficult to read or illegible	89 (47.8)	83 (44.6)	10 (5.4)	4 (2.2)	0 (0)	1.62 (0.69)
ME occurs when medication labels are of poor quality or damaged	60 (32.3)	95 (51.1)	16 (8.6)	15 (8.1)	0 (0)	1.92 (0.85)
ME occurs when there is confusion between drugs with similar names	92 (49.5)	89 (47.8)	5 (2.7)	0 (0)	0 (0)	1.53 (0.55)
ME occurs when physician prescribes the wrong dose	77 (41.4)	87 (46.8)	12 (6.5)	9 (4.8)	1 (0.5)	1.76 (0.82)
ME occurs when pharmacist miscalculates the dose	91 (48.9)	87 (46.8)	7 (3.8)	1 (0.5)	0 (0)	1.56 (0.60)
ME occurs when pharmacist fills the wrong drug	102 (54.8)	78 (41.9)	4 (2.2)	2 (1.1)	0 (0)	1.49 (0.59)
ME occurs when pharmacist tells wrong or confusing instruction during dispensing	65 (34.9)	100 (53.8)	15 (8.1)	6 (3.2)	0 (0)	1.80 (0.72)
ME occurs when pharmacist is distracted by other patients or coworkers	77 (41.4)	86 (46.2)	20 (10.8)	2 (1.1)	1 (0.5)	1.73 (0.74)
ME occurs when pharmacist is tired and exhausted	68 (36.6)	92 (49.5)	21 (11.3)	5 (2.7)	0 (0)	1.80 (0.74)

Note. 1 = strongly agree to 5 = strongly disagree.

Table 3.

Attitude toward ME Reporting.

	Strongly agree	Agree	Neutral	Disagree	Strongly disagree	Mean score (±SD)
Attitude	n (%)
I fail to report the ME because I’m afraid of the reaction from superior	13 (7.0)	33 (17.7)	77 (41.4)	47 (25.3)	16 (8.6)	2.89 (1.02)
I fail to report the ME because I’m afraid of the reaction received from my coworkers	17 (9.1)	50 (26.9)	64 (34.4)	38 (20.4)	17 (9.1)	3.06 (1.01)
I fail to report the ME because most of my colleagues ignore the reporting	33 (17.7)	55 (29.6)	59 (31.7)	28 (15.1)	11 (5.9)	3.38 (1.12)
I fail to report the ME because I think the error is not serious to warrant reporting	45 (24.2)	48 (25.8)	67 (36.0)	22 (11.8)	4 (2.2)	3.58 (1.01)
I fail to report the ME because I’m afraid that I might lose the job	93 (50.0)	49 (26.3)	27 (14.5)	13 (7.0)	4 (2.2)	4.15 (1.05)
I fail to report the ME because the error does not reach or harm the patient	37 (19.9)	30 (16.1)	36 (19.4)	54 (29.0)	29 (15.6)	2.96 (1.37)

Note. 1 = strongly agree to 5 = strongly disagree.

Bivariate analysis showed that none of the variables tested showed any association with knowledge. Being female (P = .001), senior pharmacist (P = .012), and working in primary health centers (P = .014) were associated with more favorable attitude (Table 4).

Table 4.

Comparison between Knowledge on ME and Attitude Toward Reporting ME.

Variable	Knowledge					Attitude
	n (%)	Median	IQR	Mean rank	P value*	Median	IQR	Mean rank	P value*
Gender
Male	42 (22.6)	1.75	0.70	92.0	.841	3.00	1.21	64.4	.001
Female	144 (77.4)	2.00	0.70	94.0		3.50	1.00	102.0
Highest education
Undergraduate	179 (96.2)	1.70	0.70	92.8	.593	3.33	0.83	95.4	.260
Postgraduate (Master)	7 (3.8)	2.00	0.40	110.4		2.83	1.33	44.4
Work setting
Hospital	93 (50)	1.70	0.70	90.9	.403	3.33	1.00	89.0	.014
Primary health centers	93 (50)	1.70	0.70	96.1		3.33	1.00	98.0
Working experience
<8 y	150 (80.6)	1.70	0.70	124.0	.541	3.33	1.00	1.0	.012
≥8 y	36 (19.4)	1.80	0.60	84.3		3.42	0.88	85.0

Note. *Mann–Whitney U test.

Further analysis to determine association showed that knowledge on ME did not correlate well with attitude toward ME reporting (r = 0.08, P = .29).

Discussion

Annual nationwide data have shown that hospital pharmacists in Malaysia constituted the majority of personnel to report medication errors to the national database. ⁷ However, only a few hospitals/healthcare institutions are consistently active in ME reporting. ⁹ We have attempted in our study to capture the perspectives of ME among pharmacists working in public health institutions in Pahang, which was one of the states not associated with active reporting. ¹⁰

Our findings indicate that pharmacists working in public hospitals and other primary healthcare clinics had good knowledge on perceived causes of ME. It is in agreement with few other studies where the majority of healthcare professionals had adequate knowledge on ME and were competent enough to recognize them.^14,15 Medication-use process is a common component in pharmacy undergraduate curriculum. Every pharmacist has been taught the 5 rights of medication use; “the right drug to the right patient in the right dose by the right route at the right time”. These are generally regarded as a standard for safe medication practices in all settings including hospitals, clinics and community pharmacies. In addition, various strategies and health educational programs have been conducted by the Pharmacy Division, Ministry of Health. ¹⁶ So, it is not surprising that pharmacists in our study have good knowledge on ME.

It is interesting to observe that filling in prescription with the wrong drug was chosen by almost all respondents in our study as the perceived cause of ME. It may reflect a widespread concern among respondents in their daily practice. This is supported from findings in a recent multicentre study by Rajah et al, ¹⁷ which showed that filling error occurred quite substantially in public hospitals. Another perceived cause of ME, which was chosen by the majority of our respondents was confusion with drug names. This observation has also been reported by You et al ¹⁸ as one of the top perceived causes of ME among nurses. Safety issues regarding drugs with similar names or similar looks have been addressed by the Pharmacy Division of Ministry of Health. A guideline on handling of look alike, sound alike (LASA) medications is available to assist pharmacists and other healthcare professionals in minimizing medication errors and to enhance patient safety in their practice settings. ¹⁹

It appears that there is a gap between pharmacists’ knowledge of ME and their attitude toward reporting them. While the level of knowledge on ME among pharmacists was good, their attitude toward ME reporting was very poor. Only 25% of the respondents had favorable attitude toward ME reporting. We also found that there was a positive but weak correlation between knowledge and attitude. This is consistent with the national trend of poor ME reporting in certain parts of the country, which is most likely attributed to poor attitude toward ME reporting. Several studies have shown that attitudes toward reporting significantly influenced ME reporting.^20,21

Medication-use process involves many stages and is a multidisciplinary activity. ME can occur at any stage of the process. Even among different healthcare professionals, different attitudes toward reporting exist. When compared to doctors, nurses had more favorable attitude toward reporting than doctors. ¹⁵ Several factors or barriers may influence respondents’ attitudes toward ME reporting. In our study, 76.3% of respondents associated non-reporting with the risk of losing their jobs. In a general survey among International Pharmaceutical Federation member countries, fear of consequences was found to be the most common barrier to reporting. ²² Fear of consequences include effect on career progression, of getting disciplinary actions, of being blamed and of supervisor’s or colleague’s reaction.^18,23-28 Several studies have also reported health professionals’ concern about what ME reporting would have on their interprofessional relationships.^24,29 With the concern of fear of consequences among many of our pharmacists, there is a need to reassure them of confidentiality of reporting. ²² Emphasis should be given to cultivating positive working environment such as non-punitive, blame-free and supportive environment. The institution management or senior staff must demonstrate positive responses to other staff members for reporting ME. It should be viewed as a quality management process with patient safety as a top priority.

50% of respondents in our study agreed they did not report because the error was not serious enough. The nature of error or severity of the outcomes of the errors especially when the outcomes have medico-legal implications can influence the attitude toward reporting. In general, health care professionals including pharmacists, are less likely to report if they thought that the error was not serious or did not cause harm to the patient.^26,28-32 Doctors were less likely to report ME with less serious outcomes compared to pharmacists or nurses.^23,33

Where a national system is absent or not fully developed, health institutions should initiate campaigns to increase awareness and familiarize their staff with the concept and activities of pharmacovigilance and the importance of reporting. In such a setting, a full governmental support, an independent body and a sufficient number of trained personnel are required for a successful implementation of pharmacovigilance activities.^4,22 Reporting should be made easy, regardless of whether reporting to own healthcare institution or to a national pharmacovigilance system. Even though health care professionals have good knowledge about ME, unfamiliarity with the reporting system is often associated with poor reporting.^14,31 Therefore, a standardized approach to reporting and documentation is warranted.^6,34 In Malaysia, the reporting system has been upgraded, from using manual reporting forms to online reporting system. Despite having this online system, many health professionals are still reluctant to report ME even though many had encountered ME in their daily practices. This system is still underutilized in primary healthcare centers.^12,30 Likewise, some authors have attributed such underutilization of reporting system to lack of training, time consuming to report, a reporting system that was not user-friendly, and potential lack of confidentiality.^22,24,28,32 Lack of feedback is also seen as another barrier to using the reporting system. Health care professionals feel they are unable to learn from their mistakes and improve their practice.^22,28-32 Therefore, they should be given feedback of results of error analysis because they want to learn from errors reported.

In our study, we have found female pharmacists and pharmacists working in primary health centers had more favorable attitude toward ME reporting. Health care professionals often cite lack of time and having heavy workload as reasons for not reporting.^12,22,28,31 Those working in primary care health centers may not experience as much workload as those working in hospitals. ³⁵ As a result, they will have more time to file ME reports. An alternative smartphone ME reporting application has been developed to complement the current system. Findings from this study have been encouraging. ³⁶ This approach should facilitate reporting by those pharmacists working in a busy and hectic work environment.

Even though in our study population, about 80% respondents had less than 8 years working experience, pharmacists with more experience showed significantly more favorable attitude. It is possible that more experienced pharmacists are more confident and more familiar in using the reporting system than junior pharmacists. This finding has a practical implication; those who are not familiar with the reporting system especially junior pharmacists should be given more awareness training and coaching from experienced pharmacists. In contrast to nurses, more experienced nurses tend to under-report. The author reasoned that although more experienced staff have increased level of awareness of ME, at the same time they are more selective when it comes to reporting. ²¹

The main limitation of this study is that respondents in this study were only from one of the states in Malaysia. Results may be different from those states which are active in ME reporting. Hence, these findings cannot be generalized throughout the country.

Conclusion

There is a gap between pharmacists’ knowledge of ME and their attitude toward reporting them. While the level of knowledge on ME among pharmacist in Pahang was excellent, the attitude on ME reporting was very poor. Knowledge of ME did not correlate well with attitude toward ME reporting. More efforts are needed to positively influence the attitude of our pharmacists toward ME reporting.