Research in Social and Administrative Pharmacy 15 (2019) 902–906

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Research in Social and Administrative Pharmacy

journal homepage: www.elsevier.com/locate/rsap

Student observations of medication error reporting practices in community T

pharmacy settings
Patricia L. Darbishirea, Jessica C. Zhaob, Angad Sodhic, Chelsea M. Andersond,∗
a
Purdue University, 575 Stadium Mall Drive, RHPH 108, West Lafayette, IN, 47907, United States
b
Purdue University, 22344 NE 31st Street, Sammamish, WA, 98074, United States
c
Purdue University, 11 Branding Iron Lane, Glen Cove, NY, 11542, United States
d
Purdue University, 575 Stadium Mall Drive, RHPH G35, West Lafayette, IN, 47907, United States

A R T I C LE I N FO A B S T R A C T

Keywords: Background: Medication safety practices and methods for reporting errors in community pharmacies are rela-
Medication safety tively unknown.
Community pharmacy Objective: (s): The primary objective of this study was to describe student-reported data on medication safety and
Medication error reporting error reporting practices in community pharmacies, and secondarily describe student learning from this as-
signment.
Methods: Second professional year pharmacy students enrolled at Purdue University College of Pharmacy in the
United States observed and recorded medication safety and error reporting practices as part of an experiential
assignment. Data were collected from 170 unique pharmacy settings between the years 2016–2018 and analyzed
using descriptive statistics and a paired t-test to assess student learning.
Results: 51% of students reported documentation of 1–10 errors or near misses annually, with an additional 30%
reporting 11–30. Near misses were only reported 26% of the time. Errors were most commonly reported to a
pharmacy-specific reporting system (84%) and the Institute for Safe Medication Practices National Medication
Errors Reporting Program (84%). The most frequently reported error types included wrong directions (34%),
wrong drug (14%), wrong strength (13%), and wrong patient (12%). Pharmacists were observed to be inter-
rupted approximately 19 times every hour. Anonymous error reporting was typically not allowed to the phar-
macy's preferred error reporting system (71%). A policy requiring that the prescriber is contacted about errors
was observed at 77% of the sites. The most common consequences of committing an error were education/
training (72%) or progressive discipline (41%). Students reported a statistically significant increase in under-
standing of medication safety practices and methods for reporting errors in community pharmacies. (p < 0.01).
Conclusion: This data supplements existing literature on medication safety practices and error reporting in
community pharmacy settings, as well as highlights knowledge gaps outside the scope of this study.

1. Introduction including workspace design, number of prescriptions filled, number of

There is no current international consensus regarding the definition
of a medication error.1 The United States National Coordinating
Council on Medication Error Reporting and Prevention (NCC MERP)
defines a medication error as “any preventable event that may cause or
lead to inappropriate medication use or patient harm while the medi-
cation is in the control of the health care professional, patient, or
consumer.”2 Medication errors may occur in any part of the prescrip-
tion dispensing process and have the potential to cause patient harm.
Various factors can predispose a pharmacy to a medication error,
pharmacists on staff, or inadequate pharmacy technician training.3,4
Community pharmacies in the United States dispense over 4.1 bil-
lion prescriptions annually.5,6 Using a dispensing error rate of 3.2%,
published in a previous observational studies, it may be estimated that
over 131 million dispensing errors occur in community pharmacies
each year.7,8 Although national error reporting systems exist, it is not
well understood how often and by which methods that community
pharmacy personnel address and report medication errors.9,10
The primary objectives of this study were to describe student-re-
ported data regarding medication safety and error reporting practices in

∗
Corresponding author.
E-mail addresses: darbishi@purdue.edu (P.L. Darbishire), zhao462@purdue.edu (J.C. Zhao), asodhi@purdue.edu (A. Sodhi),
canderson@purdue.edu (C.M. Anderson).

https://doi.org/10.1016/j.sapharm.2019.02.009
Received 8 August 2018; Received in revised form 19 February 2019; Accepted 19 February 2019
1551-7411/ © 2019 Elsevier Inc. All rights reserved.
P.L. Darbishire, et al.
Table 1
Student Responses to Medication Safety Assessment.
community pharmacies located in the Midwestern United States, and
describe student-perceived learning from the students' experiential as-
signment.
2. Methods
Students in their second professional year of the Doctor of Pharmacy
program at Purdue College of Pharmacy participated in a 40-h week, 4-
week long required experiential rotation at an assigned community
pharmacy practice site affiliated with the Purdue Experiential Learning
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Research in Social and Administrative Pharmacy 15 (2019) 902–906
program. Most students worked at their site Monday through Friday
from 8am to 5pm, with preceptor and student requests for variation in
the schedule honored as possible. The medication safety assignment is
one of several required assignments students complete that focuses on
specific areas of pharmacy practice. In order to identify medication
safety and error reporting practices at their site and stimulate discus-
sion with their preceptor, students were asked to observe and discuss a
variety of medication safety-related practices and record responses to
questions in a published workbook, called Community Pharmacy IPPE
Student Workbook. Assignments within the workbook were developed
P.L. Darbishire, et al. Research in Social and Administrative Pharmacy 15 (2019) 902–906

Fig. 1. Consequences of errors observed in the study.

Midwest community pharmacy sites in the United States between the

years 2016–2018. Student, pharmacist, and site identifiers were re-
moved by the course instructor prior to data analysis. The oldest data
from duplicate sites were removed. In instances where two students
were assigned to the same site at the same time, one student's data set
was randomly chosen for inclusion and the other removed. The data
from this assignment were analyzed using Microsoft® Excel® (2016).
Descriptive statistics were performed for qualitative observations and a
paired t-test was used to assess quantitative data on student learning.
Students also completed a retrospective pre-post questionnaire, to re-
flect on the degree of change in their knowledge and attitudes toward
medication safety practices.

3. Results

Fig. 2. Average number of interruptions per hour, observed.
by the course coordinator through review of published best practices
and input from a variety of pharmacy practice faculty and preceptors
prior to inclusion. Workbook assignments were developed as teaching
tools for experiential curricula - not specifically for research purposes.
Students were oriented to all assignments at a group meeting prior to
their first day on rotation. After completing each assignment and re-
cording their observations and discussion notes in the workbook, stu-
dents respond to select questions in PharmAcademic - an integrated
software system that allows a College to manage experiential sche-
duling, student assignments, and a variety of assessments.11 The data
for this study was gleaned from these student responses. This retro-
spective study of deidentified student observations was deemed exempt
by the Purdue University Institutional Review Board.
A total of 377 s professional year pharmacy students observed and
recorded medication safety and error reporting practices in 170 unique
When students were asked to record how many errors and/or near
misses at their pharmacy site were officially documented and reported
in the last year, 51% of students (n = 86) responded with the range of
1–10, with an additional 30% of students (n = 51) reporting the doc-
umentation of 11–30 errors or near misses. The most frequently re-
ported error types in the community pharmacy settings included wrong
directions (34%), wrong drug (14%), wrong drug strength (13%), and
wrong patient (12%).
The individual responsible for managing medication errors was
most commonly the pharmacy manager (54%) or a staff pharmacist
involved with the error (32%). Other options included technician or
intern (3%), district or regional manager (1%), store manager (1%), or
pharmacy legal department (0%). Errors were reported to a pharmacy-
specific error reporting system (84%) and the Institute for Safe
Medication Practices National Medication Errors Reporting Program
(ISMP MERP) 84% of the time or the Federal Drug Administration
(FDA) MedWatch (14%). Relatively few pharmacies reported “close
calls” (26%) or errors that did not reach the patient by chance as

Table 2
Students' agreement with assessment statements.a
Retrospective Pretest Mean (SD) Posttest Mean (SD) P Value

I understand how medications are arranged in a pharmacy and how this influences safety. 3.51 (0.87) 4.41 (0.41) < 0.01
I can describe optimal prescription processing and dispensing procedures. 3.28 (0.90) 4.23 (0.43) < 0.01
I recognize when ISMP error prone abbreviations are used in a pharmacy. 2.94 (0.93) 4.08 (0.43) < 0.01
I can describe the various causes/risks for medication errors. 3.45 (0.71) 4.34 (0.41) < 0.01
I can describe the various error reporting systems. 2.74 (1.00) 3.92 (0.47) < 0.01
I can describe specific ways to deter medication errors in the community pharmacy setting. 3.13 (0.84) 4.18 (0.43) < 0.01
Overall, I learned valuable information from this assignment. – 4.28 (0.05) –

a
Rating scale used: 1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, 5 = strongly agree.

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P.L. Darbishire, et al.
defined by the United States Agency for Healthcare Research and
Quality, Patient Safety Network (AHRQ PSNet).12 Anonymous error
reporting was typically not allowed to the pharmacy's preferred error
reporting system (71%) (Table 1).
Most pharmacy sites had a policy to contact the patient if an error
occurred (92%), however fewer sites required that the prescriber be
alerted of the medication error (77%). When students were asked
“What are the consequences, if any, for an individual who commits an
error?” the students collectively described that 72% of the time the
individual received education and training on the prevention of medi-
cation errors, while 41% of those who committed an error received
progressive discipline (Fig. 1). Students were allowed to describe
multiple events and consequences.
Students were also asked to observe the pharmacists work flow, and
reported that pharmacists were interrupted approximately 19 times
every hour, although some student observations reported up to 100
interruptions per hour (Fig. 2).
Finally, a comparative analysis of the students' pre-post ques-
tionnaire data about their observation assignment demonstrated a sta-
tistically significant increase in understanding of medication safety and
error reporting practices in community pharmacies. The specific areas
included pharmacy design for safety, use of ISMP unapproved ab-
breviations, optimal prescription processing, cause of medication er-
rors, error reporting systems and how to prevent medication errors
(p < 0.01) (Table 2).
4. Discussion
The overall number of reported errors from our data falls well below
previous estimates for medication error rates.7,8 This is likely due to the
fact that students were only asked to record those errors and near
misses that were documented. Underreporting in the community
pharmacy setting is commonplace due to time constraints, lack of
knowledge/access to reporting systems, fear of legal or disciplinary
action, embarrassment, organizational and logistical factors, or simply
reporter burden.9,13 Previous studies have noted that independent
pharmacies are significantly more likely to report to an external re-
porting system as compared to chain, supermarket, or mass merchan-
disers9 which may be due to lack of a standardized corporate error
reporting mechanism, or in some cases, more time to access an online
national reporting systems.
The most common error types reported by students were similar to
those reported in previously published studies, with the exception of
“wrong patient”, which was reported more frequently in the student
observations.4,7 Most pharmacies had a policy to contact the patient if
an error occurred, but fewer had policies to alert providers that a
medication error occurred. This is not surprising - but concerning, in
regard to optimal patient care. The importance of pharmacist-physician
collaboration is highlighted in the United States Joint Commission of
Pharmacy Practitioners' Pharmacist's Patient Care Process and should
be a part of the medication error reporting process as well.14
The observed consequences for the individual who committed the
error were primarily education and training (72%) followed by pro-
gressive discipline (41%) (Fig. 1). These results reflect a more blame-
centered culture in regards to error reporting. The United States Ve-
terans Affairs National Center for Patient Safety notes that education
and training are weak mitigation strategies for preventing future
medication errors and individuals are less willing to report errors if they
fear disciplinary action or termination.13,15,16 More effective strategies
to reduce the number of medication errors include reducing the number
of distractions, using checklist or cognitive aids, or simplifying and
standardizing the prescription dispensing process.15 Community phar-
macies should make efforts to create just culture environments that are
focused on process changes to the medication dispensing process as
opposed to blaming specific individuals.17
The pharmacy work environment has been cited as a contributing
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Research in Social and Administrative Pharmacy 15 (2019) 902–906
factor to medication errors.3,4 In the United States, a growing percen-
tage of community pharmacists rate their workload as high or ex-
cessively high.18 Our data describes observed frequency of pharmacist
interruptions, which has been associated with medication errors.19
Steps should be taken to reduce the number of pharmacist interrup-
tions, especially during critical task such as prescription or product
review.
Finally, the purpose of the students' observation assignment was to
increase student awareness of community pharmacy safety practices
and medication error reporting processes, which was evidenced from
the results of their responses to the pre/post questionnaire.
The questions and student responses used in this study were not
designed as research, but instead as part of experiential education
curricula, focusing on stimulation of discussion and student reflection.
The instructor recognized retrospectively that the data collected could
address existing knowledge gaps on medication safety practices in
community pharmacy settings - therefore, a traditional study design
method was not used when developing questions for the assignment.
Additional limitations to this study include that data was collected
primarily from the Midwest area of the United States and may not re-
present community practices across all regions of the US. Also, students
likely observed mixed practices and received variable and conflicting
responses from pharmacy staff members at the same site. This required
students to assimilate their observations, reflect on the overall culture,
and provide their “best” response to each question.
5. Conclusion
The analysis of this data supplements existing literature on medi-
cation safety practices and error reporting in community pharmacy
settings. It also highlights knowledge gaps outside the scope of this
study, such as studies of safety culture in community pharmacy settings,
how to create a non-punitive just culture in community pharmacy
settings, and encourage collaboration with prescribers when errors
occur.17
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://
doi.org/10.1016/j.sapharm.2019.02.009.
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