Demographic characteristics of the participants
In the total sample, 92.6% of the participants were females, with a mean age of 45 years (range 29–60 years, Standard deviation (SD) = 9.54). Participant demographic details are available in Table 1.
Table 1
Demographic characteristics of the study participants (N = 27)
Variables | Total, n (%) | NG1, n (%) | NG2, n (%) | NG3, n (%) |
Number of NG participants | 27 (100.0) | 9 (100.0) | 9 (100.0) | 9 (100.0) |
Age (years): Mean (range) | 45 (29–60) | 44 (29–60) | 45 (32–56) | 46 (39–53) |
Gender Male Female | 2 (7.4) 25 (92.6) | 1 (11.1) 8 (88.9) | 1 (11.1) 8 (88.9) | 0 (0.0) 9 (100) |
Pharmacy location Rural Small town (under 100.000 citizens) Middle town (100–200.000 citizens) Big town (more than 200.000 citizens) | 0 (0.0) 4 (14.8) 4 (14.8) 19 (70.4) | 0 (0.0) 2 (22.2) 0 (0.0) 7 (77.8) | 0 (0.0) 2 (22.2) 2 (22.2) 5 (55.6) | 0 (0.0) 0 (0.0) 2 (22.2) 7 (77.8) |
Abbreviation: NG- Nominal Group |
Please insert Table 1 here. Demographic characteristics of the study participants (n = 27)
The groups were homogeneous, as evidenced by a Pearson chi-square value of 0.352 and a likelihood ratio of 0.140, which confirmed the comparability and consistency across the NG.
NG ranking of the significance of the event
The pharmacists identified four distinct incident categories related to a specific incident and their impact on the SVP. These include "Dispensing failures", "Counselling failures", "System failures", and "Other". Within the "Dispensing failures" category, three failure themes were identified: "Wrong drug dispensed", "Wrong dose dispensed", and "Wrong pharmaceutical form of the drug dispensed". Table 2 presents the final rankings for each failure theme, as evaluated by pharmacists in terms of their contribution to the SVP, and Appendix 3 provides comprehensive details of each incident, listing the top 5 situations ranked by group voting.
Table 2
Final rankings of high-scoring incidents threatening patient safety
Theme | Top 5 1 | Top 5 2 | Number 1 | Number 2 | Average 1 | Average 2 | Final Rank |
Inadequate pharmaceutical service | 4 | 8 | 4 | 8 | 2.4 | 8 | 8.0 |
Wrong drug dispensed | 8 | 9 | 12 | 9 | 2.1 | 5.5 | 7.8 |
Wrong dose dispensed | 1 | 6 | 2 | 6.5 | 2.2 | 7 | 6.5 |
Inadequate space for counselling | 1 | 6 | 1 | 3 | 4.7 | 9 | 6.0 |
Wrong pharmaceutical form of drug | 1 | 6 | 1 | 3 | 2.1 | 5.5 | 4.8 |
Supply chain failure | 0 | 2.5 | 2 | 6.5 | 0.6 | 3 | 4.0 |
Inadequate technical service | 0 | 2.5 | 1 | 3 | 0.9 | 4 | 3.2 |
Covid-19 pressures | 0 | 2.5 | 1 | 3 | 0.4 | 2 | 2.5 |
New rules of the Republic Fund for Health Insurance | 0 | 2.5 | 1 | 3 | 0.1 | 1 | 2.2 |
Top 5 1: The frequency with which specific statements within themes appeared in the top 5 in the raw data. Number 1: The number of statements classified under each theme. Average 1: The mean score for statements within each theme based on the raw data. Top 5 2: Recalculated frequencies of statements within themes appearing in the top 5 according to the Van Breda methodology. Number 2: The recalculated count of statements for each theme, based on the Van Breda methodology. Average 2: Following the Van Breda methodology, the recalculated average scores for statements within each theme. Final Rank: The average scores of the Top 5 2, Number 2, and Average 2. |
Please insert Table 2 here. Final rankings of high-scoring incidents threatening patient safety
According to the average score, the incidents with the most significant impact on patient safety and pharmacist safety were "A patient sustained physical injuries after falling through the floor door to the basement" (4.4), "Progesterone was dispensed instead of testosterone" (4.2), and "Acenocoumarol was dispensed instead of aminophylline following breast cancer surgery" (4.0).
Frequency distribution of incidents
Dispensing errors accounted for most incidents, 63.0% of the total, as detailed in Table 3. Among these, dispensing incorrect drugs was the predominant failure theme, accounting for 44.4% of all cases. "Near misses" and "no harm incidents" dominated in safety categories at 33.3% each, and "harmful incidents" followed at 25.9% (Table 3).
Table 3
Frequency distribution of incidents by cause and impact on patient safety
# | Incident Category/ Failure Theme | % (N = 27) | # | Safety Category | % (N = 27) |
1 | Dispensing failures/ Wrong drug dispensed | 44.4 | 1 | A near miss ͣ | 33.3 |
2 | Counselling failures/ Inadequate pharmaceutical service (lack of advice) | 14.8 | 2 | A no harm incident ᵇ | 33.3 |
3 | Dispensing failures/ Wrong dose dispensed | 11.1 | 3 | Harmful incident ͨ | 25.9 |
4 | Dispensing failures/ Wrong pharmaceutical form dispensed | 7.4 | 4 | Financial loss, not affecting patient safety | 3.7 |
5 | System failures/ Supply chain failure (lack of drugs) | 7.4 | 5 | Unknown health outcome | 3.7 |
6 | Other/ Covid-19 pressures | 3.7 | | | |
7 | Other/ Inadequate space for counselling | 3.7 | | | |
8 | Other/ Inadequate technical service | 3.7 | | | |
9 | System failures/ New rules of the Republic Fund for Health Insurance | 3.7 | | | |
ͣ "An unplanned event that had the potential to result in injury, illness or damage – but fortunately it did not." ᵇ "Reaching the patient but causing no discernible harm." ͨ "Incident that results in harm to a patient (disease, injury, suffering, disability, or death)." (according to the ERNST Training Manual) |
Please insert Table 3 here. Frequency distribution of incidents by cause and impact on patient safety
Core consequences for pharmacist safety
The three groups identified the top five consequences for pharmacists' physical and mental health, including implications for pharmaceutical practice, as shown in Table 4. Appendix 2 in the supplementary material provides a detailed overview of participants' statements per theme, while Appendix 4 details the scores for each theme.
Table 4
Final rankings of pharmacists’ mental, physical, and job-related outcomes
Theme | Top 5 1 | Top 5 2 | Number 1 | Number 2 | Average 1 | Average 2 | Final Rank |
Patient-centric anxiety | 2 | 6.5 | 3 | 8 | 2.2 | 6 | 6.8 |
Personal responsibility and resilience | 2 | 6.5 | 2 | 4 | 2.8 | 7.5 | 6.0 |
Future concerns and career aspirations | 2 | 6.5 | 2 | 4 | 2.8 | 7.5 | 6.0 |
Reflective self-evaluation | 2 | 6.5 | 2 | 4 | 2.1 | 4.5 | 5.0 |
Organisational dissatisfaction | 2 | 6.5 | 2 | 4 | 2.1 | 4.5 | 5.0 |
Professional environment impact | 2 | 6.5 | 2 | 4 | 2.0 | 2.5 | 4.3 |
Self-management strategies | 1 | 2 | 3 | 8 | 2.0 | 2.5 | 4.2 |
Physical manifestations of stress | 1 | 2 | 1 | 1 | 4.9 | 9 | 4.0 |
Emotional stressors | 1 | 2 | 3 | 8 | 1.5 | 1 | 3.7 |
Patient-centric anxiety: Concern for patient health affecting mental well-being. Personal responsibility and resilience: Guilt and resilience efforts. Future concerns and career aspirations: Career uncertainty and aspiration for change. Reflective self-evaluation: Self-assessment of confidence and mental health. Organisational dissatisfaction: Frustration from workplace issues. Professional environment impact: Improved supportive and efficient practices. Self-management strategies: Coping techniques for emotional challenges. Physical manifestations of stress: Symptoms such as insomnia due to work stress. Emotional stressors: Emotional challenges and fear of adverse outcomes. |
Top 5 1: The frequency with which specific statements within themes appeared in the top 5 in the raw data. Number 1: The number of statements classified under each theme. Average 1: The mean score for statements within each theme based on the raw data. Top 5 2: Recalculated frequencies of statements within themes appearing in the top 5 according to the Van Breda methodology. Number 2: The recalculated count of statements for each theme, based on the Van Breda methodology. Average 2: Following the Van Breda methodology, the recalculated average scores for statements within each theme. Final Rank: The average scores of the Top 5 2, Number 2, and Average 2. |
Please insert Table 4 here. Final rankings of pharmacists’ mental, physical, and job-related outcomes
Pharmacists identified "Patient-centric anxiety" as the most consequential outcome, with a final rank of 6.8. "Personal responsibility and resilience" and "Future concerns and career aspirations" are closely related, with ranks of 6.0 each. The least impactful were "Physical manifestations of stress" at 4.0 and "Emotional stressors" at 3.7.
Patient behaviour and communication in incident situations
"Uncooperative/aggressive behaviour" was rated highest at 2.3, followed by "Cooperative behaviour" at 2.0, and "Neutral/no significant reaction" at 1.7. A complete analysis is detailed in Appendix 5 in supplementary material.
Response or action to support the pharmacist as an SV
Participants unanimously agreed that support is crucial in SVP recovery. Table 5 provides an overview of the ranks, where "Colleague/Peer support" was the most highly ranked theme at 5.3, followed by "Family support" at 3.7. For a comprehensive description of the statements within each theme, refer to Appendix 2, while detailed rankings are available in Appendix 6.
Table 5
Final rankings of high-scoring supporters in incident situations
Theme | Top5 1 | Top5 2 | Number 1 | Number 2 | Average 1 | Average 2 | Final Rank |
Colleague/Peer support | 3 | 6 | 3 | 6 | 4.0 | 4 | 5.3 |
Family support | 2 | 4.5 | 2 | 4.5 | 3.2 | 2 | 3.7 |
Management support | 2 | 4.5 | 2 | 4.5 | 2.7 | 1 | 3.3 |
Sharing responsibility | 1 | 2 | 1 | 2 | 5.0 | 6 | 3.3 |
Personal resilience | 1 | 2 | 1 | 2 | 4.8 | 5 | 3.0 |
Mentorship support | 1 | 2 | 1 | 2 | 3.7 | 3 | 2.3 |
Top 5 1: The frequency with which specific statements within themes appeared in the top 5 in the raw data. Number 1: The number of statements classified under each theme. Average 1: The mean score for statements within each theme based on the raw data. Top 5 2: Recalculated frequencies of statements within themes appearing in the top 5 according to the Van Breda methodology. Number 2: The recalculated count of statements for each theme, based on the Van Breda methodology. Average 2: Following the Van Breda methodology, the recalculated average scores for statements within each theme. Final Rank: The average scores of the Top 5 2, Number 2, and Average 2. |
Please insert Table 5 here. Final rankings of high-scoring supporters in incident situations
Circumstances and recommendations for improvement
The qualitative examination of statements revealed specific circumstances leading to incidents and recommendations for future practice improvement. Participants attributed adverse outcomes in pharmacies to various factors like: "Crowded pharmacy with a lot of patients, compounded by staff shortages and an unsupervised pharmacy intern", "One pharmacist was responsible for an increased number of patients present in the pharmacy simultaneously, with medications stored near each other". Post-incident improvements and recommendations included: "Following the incident, adjustments were made to the space safety", "Improvement in dispensing processes", "The solution involves keeping similar medication packages separately and labelling doses on shelves", and "Recommendations for soft skill enhancement and communication refinement". Refer to the supplementary material and Appendices 7 and 8 for detailed participant statements on each situation.
Statistical analysis
The chi-square test results indicated a significant relationship between incident categories and failure themes, with a p-value less than 0.001. Among "Dispensing failures", the following was recognised: wrong drug dispensed (70.6%), wrong dose dispensed (17.6%), and wrong pharmaceutical form dispensed (11.8%). Analysis of the "Wrong drug dispensed" category revealed that 50.0% of the respondents had "near misses", 25.0% had "no harm" incidents, 16.7% had "harmful" incidents, and 8.3% had unknown outcomes. Considerable variability in failure themes across groups was noted, particularly in Group 3, where 66.7% of all incidents involved "Wrong drug dispensed". The Pearson chi-square test for Group 3 showed marginal significance (p = 0.061), whereas the likelihood ratio test indicated significant differences (p = 0.025). The Pearson chi-square test yielded a p-value of 0.041, suggesting statistical significance in the relationship between failure themes and safety categories; however, the likelihood ratio test did not (p = 0.531). The tests revealed no significant association between safety categories and pharmacists' mental, physical, and job-related outcomes (p = 0.451).