Subtheme: Limitations of pharmacy space and medication storage.

Participants described ways in which the layout of the pharmacy, specifically the design and configuration of the dispensary area, could predispose to risk of medication errors [31,57]. For example, participants described how organisation and tidiness of shelving systems is important to avoid incorrect ‘picking’ errors [31,57].

“You’ve got to have a tidy dispensary or things do get muddled up and then when you’re working fast you’re just leaping around, grabbing things off the shelf, and unless things have been put in the correct place it’s so easy [to make a mistake] [Locum pharmacist, Group 9]” [31]

In two studies, inappropriate medication storage conditions were identified as a causative factor for medication errors [33,57]. Participants raised concerns about disconnecting electricity at night and reconnecting it in the morning, noting that such temperature variations could compromise the quality of medications and potentially lead to their degradation [33]. They also highlighted the issue of storing medications with similar names in close proximity on shelves increasing the risk of errors [57].

“It is a matter of saving electricity just like groceries. At night, they disconnect the refrigerator containing milk to save electricity, and when they come back in the morning, they turn on the electricity. (Male pharmacy user group-4)” [33]

Subtheme: Challenges with medication packaging.

Participants also expressed concerns about the lack of standardised packaging and labelling in addition to frequent changes of subsidised medications by funded agencies [31,57]. These changes result in variations in appearance and nature of medications increasing the risk for dispensing errors [57].

“However, it should be pointed out that PHARMAC, the medicines funding authority, does make regular changes to the schedule of funded medicines. This often leads unexpected changes in the appearance and nature of various medicines as different manufacturers are subsidized for the same drug formulation. This situation adds an extra element of risk in today’s dispensing environment, and is an area where pharmacists must be eternally vigilant.”(HDC10- Advisor/Pharmacist) [57]

Subtheme: Managing typical interruptions within the pharmacy.

Across several studies, interruptions in the pharmacy were identified as critical contributors to medication errors in community pharmacy settings [31,32,51,53,56,57,59]. Participants frequently reported experiencing interruptions in workflow due to simultaneous demands such as patient consultations, pharmacy staff communications, ringing telephones, as well as work meetings and conference calls [31,51,53,56,57,59].

“They use being “salaried exempt” as a way to get free work done from the pharmacists. We are expected to go to work meetings and be on conference calls on our days off unpaid. We are made to rush and do the job of a pharmacist and tech to keep the pharmacy afloat from understaffing. The open environment, being constantly distracted from patients interrupting us (open floor plan), and the phones ringing off the hook with not enough bodies to answer the phone leads to a truly stressful environment that makes it difficult to safely multi-task. More mistakes are being made.” [51]

One study reported that watching television in the pharmacy during medication dispensing is a source of distraction for pharmacy staff [32].

“Viewing television seems to be part of work culture. From about 9.15 to noon, the staff was viewing television whilst dispensing medicines. During the television viewing period, attention of the staff was very distracted. JH recorded: 9.18. There is a television playing on the dispensing counter... There is constant attention on the TV. At one point a customer was left waiting as Counter Assistant (CA) was occupied watching TV. She (CA) has been reminded that a customer was waiting. The television was firmly stationed on the front counter and appeared to be part of the pharmacy’s hardware. To confirm this, a researcher collecting data for a different work stream of this project reported watching television (during his lunch break) at this pharmacy” [32]

Subtheme: Workforce and resource pressures.

Staff shortages, as well as difficulties in recruiting and retaining adequately trained and qualified pharmacy personnel, were recognised as significant contributing factors to medication errors in three studies [51,57,59].

“[Mr B] said the pharmacy was ‘extremely busy’ and he lamented the difficulties in attracting pharmacists to our rural pharmacy’. This is by no means an excuse, but is a very important context for the error.” (HDC09-Advisor/ Pharmacist) [57]

“Not enough help! Quality help! Takes a long time to train someone and then they leave for better pay and less stress” [51]

An additional strain that was discussed by several participants related to workload pressures, including volume of work and long working hours, as being contributors for medication errors [32,51,56,57,59]. Pharmacists often reported managing multiple responsibilities, such as dispensing prescriptions and consulting with multiple patients concurrently. Participants described how this high workload frequently led to rushing prescription processing without a proper clinical check, increasing pharmacist stress and potentially increasing the risk of medication errors [32,33,51,56,57,59].

One participant expressed concerns of making medication errors due to overworking and not taking breaks. The participant also offered recommendations on the enhancement of workplace conditions especially for pharmacists who are pregnant and/or post-partum. Suggestions related to allocation of time and space for resting and breastfeeding to potentially reduce medication errors as a result of pressure and over-working [51].

“Giving pharmacists a 30 minutes lunch break or 1 hour for pregnant moms to pump and eat can make a huge impact positively in work conditions. Pregnant moms not able to sit or drink water working for more than 12 hours can cause a serious negatively health impact to which I am concerned. When I was pregnant with my first child. I wasn’t able to eat or use the bathroom because I am constantly interrupted with immunizations. i.e., influenza shots, doctor’s calls, patient questions, telephones, technicians needing help, clerk not knowing what to do. The list goes on. Having a chair in every pharmacy for pregnant moms will surely help the mom with her health and making sure her health is taken care of. My biggest concern is making medications error from over working and not taking breaks due to fear of falling behind. Even worse, losing a baby from constantly standing and not able to use the bathroom which lead to UTI which in return does harm to the baby and the mom. The work conditions in community pharmacy is very harsh and dangerous to work in. We cannot afford to make medications error and pharmacists need to eat. We are not robots and I need to eat for my growing baby.” [51]

Moreover, pharmacists also articulated it was challenging to find time for professional development due to workload pressures [33].

“He has long working hours and that leads many pharmacists to not refresh their information.[by attending workshops for continuing their education], …there is no role for the Ministry to update your information. For example, the pharmacist (Community pharmacy group-4) graduated in 1986 and necessarily many improvements[updates] have taken place since that time.” (Community pharmacy group-2) [33]

In several studies, pharmacists indicated the financial difficulties faced [31–33,51], with funding [33] and wage and staff cuts [31] being examples that then impacted on the risk of errors occurring. One study, in particular, reflected specifically on balancing the profitability of a pharmacy as a business alongside needing to ensure patient safety [33]. In this study, participants described the pharmacists’ frustration with having to work on a Friday, which is typically considered a weekend in Saudi Arabia [33].

“I don’t expect anything from the pharmacist, because all pharmacists are frustrated and this is due to their low salaries and the nature of their work. In a pharmacy, I noticed a pharmacist working in the middle of a hot day on Friday and he used to walk three or four kilometres.” (Male pharmacy user group −5) [33]

In one study, there was description of how decreased investment in automation and safety-enhancing pharmacy operations may also contribute to medication errors [51].

“Pharmacies used to be able to afford safety features and automation but even that cannot longer be afforded” [51]

Subtheme: Management pressure on pharmacists.

Pharmacists underscored the tension between management-directed performance metrics and patient-centred care in pharmacies [32,33,51]. Pharmacists reported feeling compelled to meet prescription targets, rather than focusing on patient outcomes; many described how they may face disciplinary actions if they were non-compliant with reaching targets [33,51].

“Problems between you and the owner arise; he [the owner] asks what happened … [you] pay a penalty, close the pharmacy and your license is suspended. These problems face us and affect our work.” (Community pharmacy group-4) [33]

In two studies, participants reported it was a struggle to provide comprehensive consultations, such as systematic ‘Medication Use Review (MUR)’, due to time limitations and management surveillance [32,51].

“It is conflicting, because you care about your patients and you think it’s not about targets. Like the old lady that came in and she was talking about her painkillers when she has a headache. I noted that down, I could use that as an MUR in the sense that I did sort of tell her that she’s not supposed to be taking them all the time. It’s good that you can use it, because it’s exactly what it is, you are telling the patient how to use them and advising them about it. Those are the little things that I have to concentrate on and pick up on to meet my targets.” [32]

In these studies, pharmacists also indicated that their clinical expertise was undermined when their professional judgment was being questioned for the purpose of enhanced patient satisfaction [32,51]. They also expressed frustration over the management holding them responsible for patient complaints, even if they had valid reasons for refusing to fill prescriptions or dispense medications [32,51].

“If I get a complaint I could be written up even if I had a valid reason that they had to wait I am always in the wrong and must call to apologize even if they were wrong the patient is never wrong and my professional judgment on not filling or refusing a patient is constantly being questioned and must be defended against a patient who doesn’t know anything about my job or the logistics of pharmacy billing dispensing and law.” [32]

Subtheme: Impact of commercial, insurance and financial pressures on pharmacist and physician practices.

Participants conveyed that some pharmacists and physicians were affected by financial incentives from pharmaceutical companies or driven by their profit motives leading to prescribing and dispensing of specific medications rather than addressing patient needs [31,33]. If medications dispensed are inappropriate for the patient, they may place the patient at risk of harm.

“In our country, the pharmacist gives you the medication that is suitable to him or the medication for which he receives a commission, you go to the pharmacist you say you have a headache he gives you Fevadol instead of Panadol [generic substitute] for example he gives you the medication that suits you, who he is an agent for it or gives him a commission for. Even in clinics, the representative of the company comes to the physician and gives him the new medications with tickets and gifts and the physician prescribes the medications.” (Male pharmacy user group-5) [33]

Additionally, participants discussed the impact of insurance companies on physicians’ prescribing behaviours indicating that physicians overprescribed medications to increase the insurance claims [33].

Moreover, they shared the role of Pharmacy Benefit Managers (PBMs) in restricting patients’ choices forcing them to use certain chain pharmacies, that are understaffed, therefore potentially increasing the risk for errors [51].

Subtheme: Error mitigating policies and processes.

In two studies, participants reported instances of inadequate and outdated SOPs and policies; in the examples they shared, these related to high-risk scenarios such as methadone dispensing, controlled drug storage, and incident management [57,59].

“However, I note that the pharmacy had preferred practices that it encouraged pharmacists to employ relating to its checking procedures that were not included in the SOPs at the time of events. I am critical of the pharmacy that its SOPs were not up to date to reflect its current practices.” (HDC31-HDC) [57]

In five studies, participants identified that medication errors were concealed and underreported, rather than being recognised and addressed, suggesting failure in good clinical governance [31,32,51,57,59].

“I know other pharmacists who [...] definitely stick to the rules, no matter what, and are not gonna bend ‘em. Then some people who kind of just squeeze past them. So it does depend on the person [Pharmacist, Group 2]” [31]

“There are colour baskets red, white and blue, which are supposed to be used to organize dispensing, but I have just been informed that this procedure is not usually followed.” [32]

“In my view, the number of errors at the pharmacy, and the fact that these have been made by more than one staff member, indicate a systemic problem with regard to staff failing to follow the pharmacy’s SOPs.” (HDC14-HDC) [57].

Differences in policy adherence were also noted between chain and independently-ran pharmacies. In two studies, participants shared their perspectives of chain pharmacies maintaining a firmer compliance to guidelines to ensure standardisation across all branches, compared to those that were independent [31,33]. Moreover, they stated that chain pharmacies provide training for their pharmacy staff to emphasise the implementation of regulations [31,33].

“The advantage of notifying the Head Office [of a chain] is that they then cascade the information to everybody so that every store can then separate the Xalacom and Xalitan in the fridge so that it doesn’t happen, so you’re actually avoiding the error ever happening [Locum pharmacist, Group 9]” [31]

Participants also noted across three studies the challenges of balancing adherence to protocols with the need for flexibility in clinical decision making and personalised patient care [31,33,59]. Some pharmacists indicated their readiness to bypass SOPs where compliance might not adequately address the patient’s needs, especially in humanitarian or critical cases or cases involving medication loaning [31,33,59].

“I sometimes think they’re not very helpful for patients. If you’ve got a protocol and you’ve got to do it a certain way, but then you can’t, say a checking one [...] do you break it for the benefit of the patient, even though you know you shouldn’t? [Pharmacist, Group 2] [31]

“I dispense everything; I am a pharmacist regardless of the laws, when you have a patient in front of you needing to be treated it would be difficult especially if the patient is poor and needs assistance you do not help him; for humanity” (Community pharmacy group-4) [33]

Furthermore, in one study pharmacists indicated that despite promoting a learning-centred work environment, a blame culture still persisted with emphasis on who committed the error, which could hinder accountability and transparency in reporting [31].

“[We] were taught, certainly in my era, at College, you did not make mistakes, you covered them up, that was the history. I had a boss who I could have killed because he did make mistakes but he refused to admit it. [...] [I] went in to the dispenser and said “Look, ignore him, we all make mistakes, we check each other” [Locum pharmacist, Group 9] [31]

Participants in three studies also reported poor error reporting practices reflecting inconsistent, informal and non-transparent approaches for reporting [31,56,57].

“Amending records in this way without identifying that the amendment has been made retrospectively is very poor practice. Furthermore, by making amendments to the records in this way, Mr B removed the record of what actually occurred, which is also unacceptable.” (HDC14-HDC) [57]

Subtheme: Human errors in pharmacy practice.

Three studies identified human errors as significant risks to patient safety [31,57,58]. These errors encompassed inattentiveness, forgetfulness, inadequacies in labelling, packaging, and bagging in addition to misidentification of patients and medications and insufficient assessment of patient-specific factors before medication dispensing [31,55,57,58].

“In this case, it appears that human error or haste on the part of Mr D (or another pharmacy staff member) caused Mrs A’s prescriptions to be bagged incorrectly.” (HDC08-HDC) [57]

Subtheme: Communication challenges.

In two studies, participants expressed a key challenge faced by pharmacists: the lack of communication among pharmacy staff and within and between branches of chain pharmacies [31,56]. Furthermore, pharmacists were often concerned about not being informed of recent errors and incidents [31,56].

“I [once] had an issue with methadone, [...] I did not agree with what the pharmacists had done the previous week and they’d done nothing about it all week when they had time to sort it out and then they didn’t even tell me in advance of me going, I walk in on the Saturday and get stuck with the real issue, do you give it, don’t you give it. And you’re dealing with something that’s quite, you know, can change that person quite a lot, and you’re thinking, “Well, where do you stand?” [Locum pharmacist, Group 3] [31]

An additional issue that participants indicated in one study is the breach of patient confidentiality through verbal communication particularly in small community pharmacies [53].

“There is more potential to break HIPAA [U.S. Health Insurance Portability and Accountability Act, a legislative act that protects patients’ health information]. Because we have a small pharmacy, I’ll be over here [pointing to opposite side of pharmacy] and I’ll say, ‘Hey, can you pull a prescription for [John Doe],’ or whomever the patient may be. I’ll say it across the pharmacy, so the other patients know who the person is. Whereas with the paper prescription, it’s there and you don’t even have to say anything.” [53]

Moreover, some pharmacists conveyed feeling demoralised as a result of strict company policies that hinder open communication and undervalue the importance of feedback. They also shared feeling nervous when addressing issues that include colleagues about potential negative consequences [31].

“I think you tend to get more demoralised staff in a company and more negative on feedback and communication to a well-run independent sometimes, because I think they’re sort of all put into a block and they can be boxed if you’re not careful in a company” [31]

Additionally, across three studies, participants identified communication gaps between pharmacists and patients [33,53,57] with language barriers being one of the contributing factors.

“I came across someone who didn’t know whether the medication was for constipation or diarrhoea. He said he wanted something for diarrhoea. The matter is that he didn’t want something for diarrhoea; he wanted something to cause diarrhoea. In brief, language has an effect.” (Community pharmacy group-4) [33]

In one study, some pharmacists highlighted that these communication issues are more common with e-prescriptions compared to paper prescriptions. Patients often perceive that e-prescriptions are instantly processed resulting in their dissatisfaction as a result of the delay in receiving their medications [53].

Participants also reported an argument about pharmacists’ role in patient education. Some believed that they should proactively offer patient education even if the patient does not ask while others argued that education should only be offered upon patient request. This discrepancy in expectations can potentially affect medication safety [33]. Participants also indicated having communication challenges between pharmacists and prescribers, particularly when contacting prescribers to clarify prescriptions [33,53].

“There is another concern in that it doesn’t always print the information of the doctor where they’re currently at. If you have a doctor working a walk-in or an E.R. [emergency room] and you get a prescription from them, it sometimes lists their office phone number. Then if you have a question on it and you try to call the phone number that’s on the e-prescription sometimes they’re like, ‘Oh, well they’re not here today.’ Then you have to call around or they have to bounce you around from person to person until you can find where they actually are practicing. So it makes it harder to track them down.” [53]

Subtheme: Unrealistic expectations about pharmacist practice.

Pharmacists reported having sometimes tense interactions with patients resulting in pressure affecting their dispensing practices and decisions [33,57]. In one study, participants described a case scenario in which patients pressured pharmacists to dispense antibiotics by the strip, a practice that is considered a violation in Saudi Arabia. [33].

“Originally, it is prohibited by the Ministry of Health to dispense antibiotic as a strip and if this is done it would be a violation and in case of not dispensing them in this form, the patient will go to a second, third and fourth pharmacy until he finds what he wants” (Community pharmacy group-1)” [33]

Moreover, in three studies, pharmacists highlighted patients’ lack of understanding of the dispensing process and their expectation that an effective pharmacist is one who fills prescriptions quickly without considering accuracy and quality. This created an extra pressure on pharmacists as they often felt obligated to prioritise patient satisfaction over appropriate medication dispensing and consultation [31,51,59].

“I think we’ve got to get away from the idea that a good pharmacist in the view of the public is one who gets the medication out quickly. [...] They just assume that it’s going to be correct but they don’t rank the actual quality of the dispensing in any of it, they put speed at the top [Locum pharmacist, Group 9]” [31]

Subtheme: Prescription input error, system translation and incompatibility issues.

Pharmacists listed several challenges associated with e-prescription systems, including input errors by medical staff, discrepancies between the pharmacy and the prescriber systems, and confusion in prescription details [50,52,54]. As a result of these challenges, several medication errors were undetected by pharmacists and reached patients [50].

“Pharmacist: If we’re searching and it’s not in our system exactly like it’s in the doctor’s system, even a patient name, for example, it won’t come up with that patient. If it’s, say, Cindy Smith but, at the doctor’s office, but we have her entered as Cynthia Smith, it won’t search for Cynthia because it’s searching for Cindy Smith. So then you have to delete out all that information and search for it. Same thing with the drug. If, say, in the doctor’s system it says magnesium citrate, and in our system, it says mag citrate, it won’t find the mag citrate because it’s abbreviated differently than what the doctor’s office says. So you have to kind of do a modified search in order to find the right drug.” [54]

Subtheme: Software limitations, including e-prescription control and management of outdated notes and prescriptions

Five studies identified challenges with pharmacy-based software as potential causes of medication errors [32,50,52,57,58], including lack of change-tracking features, technical malfunctions and system downtimes.

“The system has been down for about 15 minutes and so a customer’s prescription was dispensed without assistance from the computer. The pharmacist has been on the phone twice to complain and it is currently being seen to.” [32]

Several issues with e-prescription systems were highlighted, including outdated information and automated default settings which limited user control and created discrepancies with prescribers’ intentions [50,53,54,58].

“Technician: “We hear a lot when I call, it defaulted into that, or I don’t know how to get that out of there. So I’m thinking they don’t have a lot of control sometimes.”

Technician: “They tend not to take their notes off new ones. If they fax over something, they’ll say, patient needs to be seen before more refills, but they’ll give them a year’s worth of refills. And then we find out that that note is old, and they just didn’t take it off the e-script.” [54]

Subtheme: Absence of automation and technology in community pharmacies and limited integration with other healthcare institutions.

Pharmacists noted that the lack of patient records, electronic prescribing, or automation in pharmacies increases the risk of medication errors [31,33,57]. They also highlighted that the absence of an integrated system connecting pharmacies, patients, and insurance providers could result in duplicate prescriptions and potential harm [33].

“There should be a special file for each patient in each pharmacy, not only in the hospital.” (Community pharmacy group-1) [33]