Evaluation of patient safety culture in community pharmacies in Qatar

Patient safety culture is a key contributor to medication safety globally. However, the perspective of pharmacists and other personnel in community pharmacy regarding patient safety culture may vary from one country to another.


| INTRODUC TI ON
Patient safety is a crucial pillar of healthcare quality and is a key determinant of a successful healthcare system. According to the World Health Organization (WHO), patient safety is defined as "the absence of avoidable harm to a patient during the provision of healthcare and reduction of risk of preventable harm associated with care to an adequate minimum". 1 Minimising patient harm in healthcare settings is a global challenge especially in hospital care. 2 Medication errors account for approximately 25% of all incidents related to medical errors, 3 with adverse drug events (ADEs) resulting in significant proportion of injuries and death. 4 Patient safety culture takes into consideration factors that contribute to the enhancement of patient safety measures within a healthcare system, incorporating individual values, attitudes, perceptions, competencies and patterns of behaviour that determine the commitment to the proficiency of an organisation's safety management. 5,6 An organisation with a positive safety culture has characteristics such as communication based on mutual trust, prioritisation of safety and demonstration of confidence in the efficacy of preventive measures. 7 Achieving a culture of safety necessitates an understanding of the values, behaviours and norms regarding health and safety within an organisation; thus, it is crucial to unveil the underlying cultural factors present within the organisation so that safety culture can be transformed and developed. 8,9 Research has been done in healthcare to investigate organisational attributes that are believed to influence patient safety. Consequently, surveys and assessment tools have been designed and validated to evaluate safety culture that exists within healthcare organisations aiming to identify areas of strengths and weaknesses. [10][11][12][13] It is evident that pharmacists and pharmacy services can substantially improve patient safety while reducing the consequences associated with medication errors. 14 There is a growing recognition of the importance of establishing a culture of patient safety. This requires an understanding of the values and beliefs about what is important in the organisation and what attitudes and behaviours related to patient safety are expected. 15 At a global level, international healthcare organisations such as the WHO and the Joint Commission International (JCI) advocate measuring patient safety culture within healthcare settings as an effective strategy for a sustainable safety improvement. 7 Therefore, this highlights the importance of patient safety culture assessment in general healthcare and diverse settings. At the regional level, a systematic review in the Arab world revealed 'response to error' requires improvement because of perception of a blame culture. 16 Locally in Qatar, studies assessing patient safety These studies reported organisation safety initiatives and changes at the organisational levels are needed to improve patient safety culture in Qatar. 17,18 Community pharmacies are known to be one of the patient's first point of contact with the healthcare system, where pharmacists play an essential role in providing patient care in a safe manner. Patient safety in community pharmacies is portrayed through the provision of optimal therapeutic agents in appropriate doses by pharmacists to meet the health-related needs of patients or customers. 19,20 Community pharmacy staff get very busy as they work to address the varying needs of patients and customers in the pharmacy or over phone in a timely manner. As a result, there are high potentials for preventable medication errors to occur in the community pharmacy setting, where it is estimated that medication errors related to dispensing occur at the rate of approximately 1.7% in the United States (US). 21,22 Therefore, in October 2012, the US AHRQ developed and piloted the Community Pharmacy Survey on Patient Safety Culture, a survey instrument filled by pharmacy personnel to assess patient safety culture in community pharmacies. [23][24][25][26] The AHRQ pilot study reported that the main strengths observed in the patient safety culture within US community pharmacies were in the areas of patient counselling and communication openness, while the main weakness was related to staffing, work pressure and pace. Studies from other countries have assessed the patient safety culture within community pharmacy settings using the AHRQ survey. [27][28][29][30] The findings from the respective studies reported that teamwork and patient counselling were rated positively in community pharmacies, while staffing, work pressure and pace was the main area of weakness observed. [27][28][29][30] In spite of considerable advances in healthcare technology and skills of pharmacists over the past decades, patients in the Arab world are still at risk of being exposed to harm from medication errors as a result of inadequate patient safety cultures within healthcare organisations. 16,17 In Qatar, most of the research and initiatives related to patient safety have occurred in hospital and primary healthcare settings. There is paucity of information and research on community pharmacies' involvement in issues related to patient safety such What's known • Studies have found that culture of patient safety could be improved by promoting the assessment of safety culture as there exists the culture of blame when medical errors occur.
• Safety culture has been assessed in community pharmacies globally and within the Arab region, but not in Qatar.

What's new
• Community pharmacy personnel in Qatar demonstrated positive response towards patient safety culture; but indicated that staffing, work pressure and pace could be improved.
as preventing medication errors. Since community pharmacists and their supporting personnel are in the frontline of ensuring patient safety in medication use, it is important to explore their perspectives of the culture of patient safety within their practice settings.
Evaluating patient safety culture in community pharmacies grants organisations a platform to assess areas of strength and to identify areas of improvement as part of their quality improvement initiatives. Therefore, the objectives of this study were to: (a) determine the perspectives of community pharmacy personnel about patient safety culture in community pharmacies utilising the AHRQ survey in the state of Qatar and (b) identify areas of strengths and areas of improvement regarding patient safety culture in the community pharmacies surveyed.

| Sampling and survey administration
A list of licensed community pharmacists in Qatar is available from the licensing department (ie Qatar Council for Healthcare Practitioners) of the Ministry of Public Health. Based on a database of licensed community pharmacists in Qatar, and an estimate of other community pharmacy personnel, a minimum sample size of 250 was calculated with a 95% confidence interval and 5% margin of error (Raosoft ® Software). 31 Assuming a response rate of approximately 20%, and the relatively small population of registered community pharmacists, the survey was distributed to all reachable pharmacy personnel via the available e-mail addresses in the database, as well as through the pharmacy coordinator of each of the pharmacies approached.
The web-based survey was administered using SurveyMonkey ® online software (SurveyMonkey Inc). The survey link was distributed via email to all staff in various community pharmacies in Qatar. An online administration possesses the advantage of maintaining the anonymity of responses to reduce the risk of bias. Reminders were sent out to participants at different time points to increase the response rate during the 8-month study period.

| Survey instrument
The Community Pharmacy Survey on Patient Safety Culture developed by the AHRQ was used to collect the data for the study. 23 The survey which has 36 items that measure 11 composites of organisational culture to patient safety (Table 1) was first piloted in US in October 2012. In addition to the 11 composites, there are three questions related to documenting mistakes in the community pharmacy. The survey uses both 5-point agreement scale ("strongly disagree" to "strongly agree") and frequency scale ("never" to "always").
It also includes one question that asks participants to rate their pharmacy's overall rating on patient safety. Moreover, the survey response options include "does not apply", "don't know" and "other, please specify" options, which were added by the current study investigators to match the adaptations made to the survey.
No changes were made to the content of the questionnaire as the items of the 11 domains applied to Qatar and will allow comparison with similar studies globally. Additional demographic and professional characteristics questions were adapted and added to the instrument. The AHRQ survey tool was selected to evaluate the safety culture since the instrument was previously validated and possess good psychometric properties (reliability statistics based on the pilot data for the 11 respective composites ranged from Cronbach's alpha 0.68-0.89). 24 In addition, the use of a standardised, validated tool facilitates comparisons to be made across studies globally.

| Data analyses
The survey responses were exported from SurveyMonkey ® to Statistical Package for Social Sciences (SPSS) version 25 (IBM). 32 All data were analysed using the SPSS. Negatively worded survey items were reverse scored such that a higher score (ie a score of 4 or 5 on a Likert scale) meant a more positive response to the question. Descriptive statistical analysis (frequencies and percentages) was conducted to report categorical variables. percent positive responses were calculated by combining the respective percentage responses of "strongly agree" and "agree" or "always" and "most of the time". percent neutral responses represented "neither agree nor disagree" or "sometimes" response categories. percent negative responses were calculated by combining "strongly disagree" and "disagree" or "never" and "rarely" response categories, depending on the response options used for any particular item. For negatively worded items, percent positive response is based on those who responded with "strongly disagree" or "disagree" or "never" or "rarely". For each of the 11 composites, a composite percent positive response was

| Ethical approval
Ethical approval was obtained from the Qatar University Institutional Review Board (approval reference number: QU-IRB 1013-E/19). The survey was anonymous and it did not capture any identifying information of the respondents. Accordingly, the survey responses were kept strictly confidential.

| Demographic and professional characteristics of community pharmacy personnel
Of approximately 1000 pharmacy personnel who received the online link to the survey via e-mail, 240 respondents completed the survey (response rate 24%). The demographic and professional characteristics of the respondents are represented in Table 2. Notably, 87.5% of the respondents were pharmacists, while the remaining 12.5% included pharmacy technicians, pharmacy assistants and pharmacist interns. Most respondents (76.4%) were employees in chain pharmacies and around 44% had 6 to less than 12 years of pharmacy practice.

| Pharmacy personnel perceptions of patient safety culture
Responses from community pharmacy personnel regarding their perception of patient safety culture in their pharmacies are presented in Table 3, which displays the percentages of positive, neutral and negative responses for each of the survey items under their respective patient safety composites. In addition, Figure 1 illustrates   (Table 3). All three items (D1, D2 and D3) were rated positively with more than 60% positive TA B L E 1 AHRQ community pharmacy patient safety culture composites

Communication about mistakes
Staff discuss mistakes that happen and talk about ways to prevent the mistakes.

Communication about prescriptions across shifts
Information about prescriptions is communicated well across shifts, and there are clear expectations and procedures for doing so

Communication openness
Staff freely speak up about patient safety concerns and feel comfortable asking questions, and staff suggestions are valued Organizational learningcontinuous improvement The pharmacy tries to figure out what problems in the work process lead to mistakes and makes changes to keep mistakes from happening again

Overall perceptions of patient safety
There is a strong focus and emphasis on patient safety, and the pharmacy is good at preventing mistakes

Patient counseling
Patients are encouraged to talk to the pharmacist; pharmacists spend enough time talking to patients and tell them important information about new prescriptions

Physical space and environment
The pharmacy is well organized and free of clutter, and the pharmacy layout supports good workflow

Response to mistakes
The pharmacy examines why mistakes happen and helps staff learn from mistakes, and staff are treated fairly when they make mistakes

Staff training and skills
Staff get the training they need, new staff receive orientation, and staff have the skills they need to do their jobs well responses for each item. Finally, approximately half of the respondents (52.5%) rated overall rating for patient safety in their respective pharmacy as "Excellent" and about a third (31.7%) rated it as "Very good" (Figure 2).
Individual items with percent positive response less than 50% were B3 (46.1%), B9 (42.3%) and B16 (39.8%), in the "Staffing, Work Pressure and Pace" composite; C8 in the "Response to Mistakes" composite and C3 (46.2%) in the "Overall Perceptions of Patient Safety" composite. As illustrated in Table 4, the highest positive responses were demonstrated with the "Patient Counseling" composite (93%-96%) for both pharmacists and non-pharmacists, whereas the lowest positive responses were reported with the items of the "Response to

| Assessment of patient safety culture according to pharmacies and pharmacy personnel characteristics
Mistakes" composite (21%-88%). The proportion of pharmacists who felt that staff take adequate breaks during shifts was significantly higher than that of non-pharmacists (49.7% vs 27%; P = .019).
Similarly, significantly less proportion of pharmacists felt that they The influence of gender on percent positive responses was also investigated ( Table 5). The proportion of female respondents who reported experiences of being rushed when processing prescriptions (B9) was significantly higher than male respondents (53.1% Similarly, the association between the type of pharmacy and percent positive responses to respective survey items is shown in Note: Percent positive responses (PPR) are calculated by combining "strongly agree" and "agree" or "always" and "most of the time" response categories. Percent neutral responses represent "neither agree nor disagree" or "sometimes" response categories. Percent negative responses calculated by combining "strongly disagree" and "disagree" or "never" and "rarely" response categories. A1-A10, B1-B16 and C1-C8, correspond to AHRQ survey items (23). a Percent responses for "Does Not Apply or Don't Know" response categories not documented with positive, neutral or negative percent responses.
b Negatively worded questions. For negatively worded items, PPR is based on those who responded "strongly disagree" or "disagree" or "never" or "rarely", depending on the response category used for that particular item.

| Open-ended responses on perceptions of pharmacy personnel towards patient safety culture
At the completion of the survey, respondents were given the op-

| D ISCUSS I ON
To the knowledge of the authors, this study was the first in Qatar

P-value a Pharmacist
Non-pharmacist and resolve drug-related problems. 19 Moreover, the score reflects

P-value a Pharmacist
Non-pharmacist C4. This pharmacy helps staff learn from their mistakes rather than punishing them   report which pharmacy they are employed in, thus, are more likely to report bias responses to favour the practice in their respective pharmacies.

| CON CLUS ION
Findings from this study suggest that the surveyed community phar- Pharmacy for their great support in distributing the survey to pharmacy personnel who did not receive the online link. Open Access funding provided by the Qatar National Library.

CO N S E NT TO PA RTI CI PATE
Yes, informed consent was reviewed and approved by the IRB.

D ECL A R ATI O N S
The authors have no conflicts of interest to declare.

E TH I C S A PPROVA L
Yes, approval by Qatar University Institutional Review Board (IRB).