Challenges of standardized continuous quality improvement programs ...

Research in Social and Administrative Pharmacy 8 (2012) 499–508

Original Research

Challenges of standardized continuous quality improvement programs in community pharmacies: The case of SafetyNET-Rx Todd A. Boyle, Ph.D.a,*, Neil J. MacKinnon, Ph.D.b, Thomas Mahaffey, Ph.D.a, Kellie Duggan, B.Sc.c, Natalie Dowa a

Gerald Schwartz School of Business, St. Francis Xavier University, 1 West Street, Antigonish, NS, Canada B2G 2W5 b The Mel and Enid Zuckerman College of Public Health, The University of Arizona, Roy P Drachman Hall, A247, 1295 N Martin Ave., PO Box 245177, Tucson, AZ 85724-5177, USA c College of Pharmacy, Dalhousie University, 5968 College Street, Halifax, NS, Canada B3H 3J5

Abstract Background: Research on continuous quality improvement (CQI) in community pharmacies lags in comparison to service, manufacturing, and various health care sectors. As a result, very little is known about the challenges community pharmacies face when implementing CQI programs in general, let alone the challenges of implementing a standardized and technologically sophisticated one. Objective: This research identifies the initial challenges of implementing a standardized CQI program in community pharmacies and how such challenges were addressed by pharmacy staff. Methods: Through qualitative interviews, a multisite study of the SafetyNET-Rx CQI program involving community pharmacies in Nova Scotia, Canada, was performed to identify such challenges. Interviews were conducted with the CQI facilitator (ie, staff pharmacist or technician) in 55 community pharmacies that adopted the SafetyNET-Rx program. Of these 55 pharmacies, 25 were part of large national corporate chains, 22 were part of banner chains, and 8 were independent pharmacies. A total of 10 different corporate chains and banners were represented among the 55 pharmacies. Thematic content analysis using wellestablished coding procedures was used to explore the interview data and elicit the key challenges faced. Results: Six major challenges were identified, specifically finding time to report, having all pharmacy staff involved in quality-related event (QRE) reporting, reporting apprehensiveness, changing staff relationships, meeting to discuss QREs, and accepting the online technology. Challenges were addressed in a number of ways including developing a manual-online hybrid reporting system, managers paying staff to meet after hours, and pharmacy managers showing visible commitment to QRE reporting and learning. Conclusions: This research identifies key challenges to implementing CQI programs in community pharmacies and also provides a starting point for future research relating to how the challenges of QRE reporting and learning in community pharmacies change over time. Ó 2012 Elsevier Inc. All rights reserved. Keywords: Community pharmacy; Continuous quality improvement; Medication error reporting

* Corresponding author. Tel.: þ1 902 867 5042; fax: þ1 902 867 6142. E-mail address: [email protected] (T.A. Boyle). 1551-7411/$ - see front matter Ó 2012 Elsevier Inc. All rights reserved. doi:10.1016/j.sapharm.2012.01.005

500

Boyle et al. / Research in Social and Administrative Pharmacy 8 (2012) 499–508

Introduction With a number of recent high-profile cases1,2 within the health care setting involving qualityrelated events (QREs), it is imperative that pharmacy stakeholders develop in-store and collective strategies to identify and address the root causes of QREs and communicate lessons learned to prevent similar tragedies from occurring in community pharmacies. Within a community pharmacy context, QREs can be defined as medication errors that ultimately reach the patient, such as incorrect drug, dosage, quantity, as well as near misses, where the error is caught by pharmacy staff before dispensing.3 There has been very limited research exploring QRE rates in community pharmacies. Ashcroft et al,4 examining UK community pharmacies, identified QRE rates at approximately 26 errors for every 10,000 prescriptions dispensed. Perhaps more concerning than the rate of errors is the lack of formal and well-structured quality improvement programs designed to allow community pharmacy staff to collectively learn from QREs and prevent similar errors from recurring. A formal continuous quality improvement (CQI) program is an effective way for pharmacy staff to better report QREs and identify and address the key organizational and technological factors contributing to such errors. CQI is a management philosophy focused on continually identifying and addressing the root cause of errors, empowering employees to report problems without fear of negative consequences, developing open and seamless information flows, and focusing on improving overall levels of quality throughout the organization.5 Advancements in web-based and collaborative technologies have enabled the development of standardized CQI programs for QRE reporting and learning in community pharmacies. Through a common CQI program (to the jurisdiction) and using web-based systems, common databases, and online reporting and analytic tools, QRE occurrence and outcomes from one pharmacy can be disseminated to other pharmacies throughout the jurisdiction (eg, province, state, or country). Standardized CQI programs provide the tools, support, and autonomy needed for quick and easy QRE reporting and the assessment of such errors for root causes. These programs also allow pharmacies to learn from one another (despite being potential competitors), take advantage of network effects (ie, the more adopters, the better the quality of the data), and proactively address sources of QREs

before they occur. Standardized CQI programs, when fully embraced by community pharmacies, also provide much needed aggregate data on QRE reporting to allow regulatory authorities, pharmacy associations, and patient safety advocates to develop and implement strategies aimed at reducing QREs and enhancing public safety. However, despite the fact that pharmacies in many North American jurisdictions are now required to have a CQI program in place6 and the significant potential of such programs for improving patient safety, research exploring CQI challenges in community pharmacies considerably lags in comparison to service, manufacturing, and various health care (eg, hospital) sectors. Subsequently, little is known with respect to the challenges that community pharmacies face with implementing CQI programs, let alone a standardized one. As a starting point to better understanding such challenges, this research identifies the initial implementation issues faced by community pharmacies as they adopt a standardized and technology-enhanced CQI program designed to improve QRE reporting and learning. The specific objectives of this study were to 1. Identify the initial challenges community pharmacies face when implementing a standardized and technologically enhanced CQI program 2. Assess how pharmacy managers and staff addressed these early challenges

Methods This research explored the initial challenges of standardized CQI adoption through a qualitative interview research design7 involving community pharmacies that adopted the SafetyNET-Rx CQI program (www.safetynetrx.ca). This method allowed for rich data to be derived while ensuring that the CQI process followed, technological sophistication of the support tools, and expectations about how QREs were to be addressed (eg, online reporting of errors, quarterly meetings to discuss QREs) remained the same. Study setting SafetyNET-Rx is a CQI program designed to improve QRE reporting and learning in community pharmacies. SafetyNET-Rx combines the key elements of CQI with the latest in integrative information systems to provide pharmacy staff with the support (eg, processes, training, and technology) needed to identify, report, and learn


from QREs. Key program elements include a pharmacy-tailored CQI cycle, access to store-level and national aggregate data on QREs for analysis of root causes, training sessions on quality management, online reporting of QREs to a national database, and online tools for pharmacy regulatory authorities to assess compliance to SafetyNET-Rx or their QRE-related standards of practice. A core component of the SafetyNET-Rx program is CQI facilitators who are responsible for initiating quarterly meetings, as well as analyzing national and provincial data from the reporting tool to identify areas to change to proactively prevent errors from occurring. To ensure different perspectives and adequate staff representation, each pharmacy is required to have 2 CQI facilitators comprising a pharmacist and pharmacy technician. SafetyNET-Rx training follows the train the trainers format. Specifically, the CQI facilitators receive training off-site concerning QREs, quality management, and the SafetyNET-Rx program, including the core tools, forms, and processes. CQI facilitators are then asked to train their respective staff on the information they have received. The current version of the SafetyNET-Rx program is presented in Fig. 1. Following the SafetyNET-Rx program, there are a number of steps that community pharmacies are expected to take after a QRE occurs. Details of the error, potential causes, and suggested changes to prevent the error from recurring are immediately logged using a Web-based reporting tool that enables anonymous reporting to a national database. The database can be searched to identify common QREs occurring across Canada, allowing the pharmacy to proactively address potential QREs before they occur. Once the error has been logged, 2 in-store CQI facilitators can review the error and related aggregated national data on QREs. Once every quarter, or in the case of a significant QRE, shortly after the error being logged, a CQI meeting is held with pharmacy staff. The purpose of this meeting is to openly discuss the QREs that have occurred since the last meeting, identify the root causes of the QREs, and suggest process, workflow, dispensing, or technology changes that should be implemented to reduce the likelihood of similar errors from recurring. These changes, subject to management approval, are then implemented, and staff begin dispensing according to the new procedures or workflow. Pharmacy staff continue to dispense according to the new procedures until an error occurs, at which time the cycle begins again.

501

The SafetyNET-Rx program also includes an iPad-based mobile application that allows pharmacy inspectors to assess compliance to provincial standards of practice related to quality assurance in community pharmacies. The tool captures detailed information on QRE reporting and learning in individual pharmacies that was not previously captured and allows pharmacy inspectors to use an online mobile application instead of manual forms to conduct inspections. Such capabilities improve the quality of data on how well individual pharmacies report and learn from QREs. For example, instead of simply capturing the existence or absence of a CQI program, the tool captures key aspects of the CQI program that pharmacies are having difficulty with, highlights areas that must be improved before the next inspection, requires staff to self-assess their pharmacy, and allows pharmacies to trace how their performance changes over time, among other things. Procedure In April 2010, 68 community pharmacies in Nova Scotia, Canada, were selected to adopt the SafetyNET-Rx CQI program, representing (at the time) 23% of the province’s 293 community pharmacies. The pharmacies selected represented a variety of types (eg, independent, banner, chain), sizes, and locations (eg, urban, rural). None of these pharmacies were using a formal CQI program similar to SafetyNET-Rx (eg, no online reporting to a common database, no meetings to discuss QREs, limited technology used) before the study. However, one-way reporting (eg, limited feedback) of serious QREs (eg, reached the patient and caused harm) to corporate head office for the purposes of litigation assessment was occurring for pharmacies belonging to certain corporate chains. In April 2010, 2 pharmacy staff members from each pharmacy (ie, 1 pharmacist and 1 technician) attended a one-day workshop focused on QRE reporting and learning, CQI, and the SafetyNETRx program. These CQI facilitators then returned to their pharmacies and trained their staff. This research focused on the initial challenges faced with adoption, and as such we focused on the first 3 months of use, specifically enough time for a complete SafetyNET-Rx cycle. As a result, the 68 participating pharmacies were contacted for possible interviews with their CQI facilitators approximately 3 months after the training session in April. However, initial discussions highlighted that 13 pharmacies had not yet provided SafetyNET-Rx

502


Fig. 1. SafetyNET-Rx program.


training to their staff or begun using SafetyNET-Rx on a daily basis. The CQI facilitators from these 13 pharmacies were therefore not interviewed. Subsequently, a CQI facilitator in each of 55 pharmacies who had begun using SafetyNET-Rx was interviewed beginning in June 2010. Of these 55 pharmacies, 25 were part of large national corporate chains, 22 were part of banner chains, and 8 were independent pharmacies. A total of 10 different corporate chains and banners were represented among the 55 pharmacies. Semistructured interview questions were presented to the CQI facilitators and focused on staff attitudes toward QREs (eg, QRE reporting, open discussion of QREs), barriers and facilitators of SafetyNET-Rx use (eg, use of an online system), and the early impact of SafetyNET-Rx on the pharmacy (eg, staff relationships, how managers can optimize the use of SafetyNET-Rx). The interviews were designed to last for approximately 30 minutes. Ethics approval for the SafetyNET-Rx project was provided by St. Francis Xavier University, Nova Scotia. The specific open-ended questions presented to CQI facilitators were designed to elicit their overall impression of the challenges of the SafetyNET-Rx program in their pharmacy and included the following: 1. What do you perceive to be your biggest barriers to implementing SafetyNET-Rx in your pharmacy? What have your pharmacy done to overcome these barriers? 2. What were staff’s initial attitudes or interests toward QREs in general, including reporting QREs and discussing how to enhance pharmacy practice? Were these attitudes the same or different for both the pharmacists and the pharmacy technicians? 3. How do you perceive that participating in SafetyNET-Rx has affected the relationship between the pharmacists and pharmacy technicians in your pharmacy? Is it for the better or worse? 4. Have pharmacy managers been open or resistant to the concept of QREs and encouraged reporting? 5. If you had the opportunity, is there a recommendation that you would make to your head office or pharmacy owner that you believe would result in your pharmacy getting the most out of the SafetyNET-Rx process? The researchers chose thematic content analysis to examine and classify the data generated from the interviews. Content analysis is focused on “developing an objective and systematic

503

description of the manifest content of qualitative and archival data.”8 Among the various levels of abstraction (eg, counting keywords, identifying common themes) for analyzing the data when performing content analysis, we selected the meaning-oriented method that is focused on identifying key themes from the data. To derive key themes, the steps identified by Braun and Clarke9 were followed and included familiarizing oneself with the data, generating initial codes, searching for themes, reviewing themes, defining and naming themes, and reporting the results. Two researchers performed these steps independently of one another. They then met and reported on the key themes they identified. After iterative analysis and additional discussion, they reached a consensus on the key challenges faced with implementing the SafetyNET-Rx CQI program and how these issues were addressed. The complete research method is presented in Fig. 2.

Results Results of the content analysis highlighted a number of early challenges that community pharmacies may face when implementing a standardized CQI program. These early challenges included finding time to report QREs, accepting the online technology, having all staff involved in reporting QREs, changing staff relationships, and meeting to discuss QREs. These challenges and how there were addressed are presented in Table 1. Examining the interview data, it is apparent that the innovation (ie, SafetyNET-Rx) is perceived to be relatively expensive for some. Examples of how the new CQI process is perceived as expensive are illustrated in monetary terms, such as the expense needed to pay for staff meeting times, and equally importantly in nonmonetary terms. Among nonmonetary costs, pharmacies identified time (eg, time to learn a new tool, time to report, time to meet) and anxiety/stress (eg, reporting apprehensiveness, negative staff relationships). Solutions to cost-related barriers were found through simply paying the monetary costs (eg, salaries to permit people to attend meetings), through reducing the perceived nonmonetary costs underlying stress and anxiety (eg, management demonstrating increasing support, commitment, and openness), and by reframing the innovation as a long-run cost savings rather than a short-run cost driver (eg, reinforcing the merits of the program at staff meetings).


Pharmacy Selection

504

68 Nova Scotia community pharmacies with limited (e.g., manual, none, limited computerized) CQI programs in place selected to adopt the SafetyNET-Rx CQI Program

SafetyNET-Rx Training & Use

Two CQI Facilitators (one pharmacist, one technician) from these community pharmacies attend a day-long workshop on QRE reporting, CQI, and SafetyNET-Rx in April 2010

CQI Facilitators return to their pharmacies and train the remaining staff

Data Collection (Interviews)

The pharmacy begins SafetyNET-Rx

CQI Facilitators from 55 pharmacies interviewed in the summer of 2010 after completing their first SafetyNet-Rx CQI cycle, representing their first three months of use. Open-ended semi-structured questions addressed attitudes towards QREs, barriers of SafetyNET-Rx use, and impact of SafetyNET-Rx on the pharmacy.

Final Themes

Data Analysis

Data analyzed using thematic content analysis Data analyzed independently

Data analyzed independently

Initial themes identified

Initial themes identified Initial themes presented and discussed

Final themes derived

Fig. 2. Research method.

Discussion Time to report QREs immediately and completely The time to report QREs, defined as the average amount of time required to report QREs in sufficient detail (eg, complete all the required and optional fields in the online system) and as QREs occurred (ie, in real time vs batching), was the most commonly cited barrier, having been reported by 25 (45.4%) pharmacies. CQI facilitators from 18 (32.7%) pharmacies indicated that it was difficult

to find time to report as part of their daily work routine, whereas 7 (12.7%) indicated that the reporting process (eg, entering QRE data into the online system) was time consuming. To embed the new activities into the work routine, pharmacy staff using the SafetyNET-Rx program were encouraged to report QREs as soon as they occurred and to present as much detail about the incident as reasonably possible. Reporting QREs as soon as they occur offers a number of benefits including a more accurate presentation of the QRE events

Table 1 Summary of challenges regarding CQI adoption Definition

Pharmacies (n ¼ 55)

Description/observed solution

Time to report QREs

The average amount of time required to report QREs in sufficient detail (eg, complete all the required and optional fields in the online system) and as QREs occur (ie, in real time vs batching)

25 (45.4%)

- Eighteen (35.3%) pharmacies indicated that it was difficult to find time to report, and 7(13.7%) indicated that reporting is time consuming - To help provide time for reporting, staff had allotted time periods throughout the day to complete their reports - Development of a manual-online hybrid reporting system

Online technology acceptance

Pharmacy staff’s decision about how and when they will use the online reporting components (eg, reporting QREs to a national database) of the standardized CQI program Pharmacy staff being anxious or fearful that negative consequences will occur to them if they report QREs and/ or actively participate in the CQI program

24 (43.6%)

Development of a manual-online hybrid reporting system

19 (34.5%)

Pharmacy staff involvement

Regular participation by all pharmacy staff in the core components of the CQI program, including reporting QREs, participating in quality improvement meetings, and making suggestions for improving quality and safety

11 (20.0%)

Apprehensiveness was occurring in 19 (37.3%) of the pharmacies. This was addressed by managers by demonstrating support for improved QRE reporting and encouraging staff to do so - Reassurance of reporting by highlighting the value of reporting and the need for open communication regarding errors - Examination of QRE cases as a group, reinforcing how the information reported is actually used - Reinforcement of the value of the program at staff meetings and training session for staff

Pharmacy staff relationships

The impact of the CQI program on the interpersonal relationships between pharmacy staff

8 (14.5%)

- Staff relationships were affected negatively in 8 (14.5%) pharmacies. There was the belief that negative repercussions would occur such as an image of being incompetent or that their employment with the pharmacy could be jeopardized - Relationships between staff in the store were affected positively in 31 (56.4%) pharmacies, through open communication and a blame-free environment

Meeting to discuss QREs

Staff formally and collectively meeting to systematically examine reported QREs and discuss solutions to prevent recurrence

7 (12.7%)

Meetings were scheduled near the end of the day/shift combined with management paying staff to attend CQI meetings and training sessions

Reporting apprehensiveness


Challenges

505

506


(ie, logging the event while the case is still fresh in their minds) and ensuring that the QRE does get reported (ie, not forgetting to enter the report). Although it is important for the reporting process to be fast so that all QREs can be reported efficiently, it is also critically important to make sure that the reports are complete and of high quality to ensure an opportunity to learn from the information provided exists.10 Entering the QRE details required for in-store root cause analysis and for other stakeholders (eg, other pharmacies, regulatory authorities) increases the time needed to report QREs. A number of pharmacies tried to address the time issue by providing additional training on the online reporting tool to improve efficiency. Others deviated from immediate reporting by allocating specific periods of time during the workday to enter QREs online or by creating a SafetyNET-Rx basket where initial information on the error was placed if it could not be entered right away. Acceptance of the online components of the CQI program While evaluating prescription intervention practices, Mandt et al11 highlight that pharmacists preferred software and information systems to accomplish more complex and progressive interventions. The unrestricted access to information for all the involved parties (ie, pharmacists, technicians, and patients) generated open and uncensored dialogues, whereas the circulation of this information led to a heightened detection of errors.11 Subsequently, a standardized CQI program with enhanced technological capability (eg, reporting and analytics) and information sharing across the jurisdiction or country has the potential to improve patient safety well beyond that of insularfocused CQI programs that are limited to a single pharmacy or chain. Critical to the success of such systems are communication and information technologies, which must be fully embraced by pharmacy staff to achieve the full benefits of a standardized CQI program. Modifying the technology acceptance definition presented by Davis,12 a definition for online technology acceptance is pharmacy staff’s decision about how and when they will use the online reporting components (eg, reporting QREs to a national database) of the standardized CQI program. Despite the fact that SafetyNET-Rx had complete online reporting capability, 24 (43.6%) pharmacies did not fully accept the online system

for various reasons including the fear and stigma of being seen reporting, not knowing exactly what to report, and not being completely comfortable and confident with using the online system. These issues combined with staff not having sufficient time to report QREs as they occurred led to pharmacies incorporating their own manual component into the reporting process. Although encouraged to report QREs as they happen, 17 (30.9%) pharmacies developed a hybrid manualonline approach focused on reporting QREs in daily batches. The process of reporting on paper first before submitting it online was adopted for a number of reasons, including time constraints (ie, process was taking too long) to record informative notes or to prioritize important facts during a hectic workday and produce a hard copy for the pharmacy’s own proprietary records. Of the 27 (49.1%) pharmacies who solely used the online reporting tool, 9 (16.4%) pharmacies with experience using a manual process before SafetyNET-Rx stated that the paper forms created more work, were time consuming, and were ultimately inefficient. Reporting online was described as being much easier and quicker and that filling out a paper form was a tedious task. Research conducted by Mustonen-Ollila and Lyytinen13 found that a key factor of information systems innovation success was ease of use. This finding also conforms to the relative advantage and complexity aspects of Rogers theory of innovation diffusion.14 The perceived ease and efficiency of the program is an important factor in implementation success. Staff apprehensiveness, involvement, and relationships CQI programs, such as SafetyNET-Rx, only work if all pharmacy staff members are willing to report and openly discuss QREs. Pharmacy staff who are vocal against reporting can very easily deter others from reporting. For example, pharmacy technicians may be reluctant to report QREs that may indirectly involve pharmacists (eg, pharmacist on duty when the QRE occurred) who are openly against QRE reporting. Results of the interviews highlighted QRE reporting apprehensiveness for a number of pharmacies, which may be defined as pharmacy staff being anxious or fearful that negative consequences will occur to them if they report QREs and/or actively participate in the CQI program. Initial apprehensiveness toward QRE reporting occurred in 19 (34.5%) of the pharmacies. Overall, however, there seems to


have been a general improvement in staff relationships. CQI facilitators from 31 (56.4%) pharmacies highlighted that the impact of the CQI program on the interpersonal relationships between pharmacy staff was positive, whereas only 8 (14.5%) pharmacies reported that the staff were affected negatively by the CQI program. Of the respondents who perceived the establishment of better staff relationships, 16 pharmacies (29.1%) identified that relationships were positively affected by creating open communication and a blame-free environment; achieved in part by managers openly supporting QRE reporting and encouraging staff to do so. CQI facilitators within those pharmacies where tensions were apparent between staff attribute such outcomes to the belief that negative repercussions would occur such as an image of being incompetent or that their employment with the pharmacy could be jeopardized. Related to QRE reporting apprehensiveness, having all pharmacy staff fully involved in the CQI program was an early issue that many pharmacies had to address, with such involvement being operationalized as the regular participation by all pharmacy staff in the core components of the CQI program, including reporting QREs, participating in quality improvement meetings, and making suggestions for improving quality and safety. Staff involvement in the CQI program was the largest issue for 11 pharmacies (20.0%). One pharmacy highlighted a case where a staff member was not supportive of the program and encouraged others not to report QREs, thus limiting critical buy-in of the program. Previous research has documented possible increased tensions between pharmacists and pharmacy technicians through new process changes and technologies. For example, Novek15 highlights that technologies, such as drug automation, have increased tensions between pharmacists and technicians. Given the potentially extensive process, technology, and culture changes required when implementing a CQI program, tensions between staff may present a major challenge prohibiting program success. The literature shows that negative experiences involving medication incidents can create tensions in the workplace, which tend to deter future error reporting.16 Pharmacies addressed buy-in issues in a number of ways, including efforts focused on taking the fear out of reporting, such as highlighting the value of reporting, and the need for open communication regarding errors. One pharmacy had gone through a number of QRE examples as a group and

507

discussed how they should be properly reported, thus reinforcing how the information would be used. Others reinforced the value of the program at staff meetings and/or held training sessions for staff. Meeting to discuss QREs The early CQI implementation challenges presented thus far stem from the process of reporting QREs, specifically getting QREs into the database. However, standardized CQI programs such as SafetyNET-Rx are of limited value if reported QREs are not analyzed for root causes and appropriate process, technology, and dispensing changes are not made. For example, Knudsen et al17 highlight that errors are corrected and minimized when identified, recorded, and evaluated using an ongoing process and cyclical implementation of CQI. Although the process of reporting errors online is structured and can be done individually, learning from these errors and making appropriate changes are very much unstructured and require the participation and unique insight from all pharmacy staff members. The challenge of staff formally and collectively meeting to discuss reported QREs (be it ones occurring in the pharmacy or elsewhere) and recommending improvements within already busy work schedules was a learning barrier identified by 7 (12.7%) pharmacies. This finding is congruent with prior research involving community pharmacies, which found that the activity of staff training receives less time compared with all other professional tasks.18 Scheduling meetings near the end of the day/shift combined with management paying staff to attend CQI meetings and training sessions addressed this issue. Furthermore, research found that in addition to the time barrier, not being clear on the goals of the quarterly meetings and how to perform root cause analysis were also barriers. Incidents of error reporters having difficulty performing root cause analysis have also been found in prior studies of error reporting.19

Conclusion This research identified the early challenges faced by community pharmacies as they implement a standardized CQI program designed for improved QRE reporting and learning. There are a number of limitations to this study that should be kept in mind when applying the findings. First, additional insight may have been gained by

508


interviewing stakeholders beyond CQI facilitators, including pharmacy managers, staff pharmacists, pharmacy technicians, and patients. Second, before conducting the interviews, we verified that the pharmacies did provide training to their staff on SafetyNET-Rx. However, we only assessed if they provided training and not the quality of the training or staff participation. The extent and quality of the training that staff received may have impacted the challenges faced. Third, the data were grouped into themes by the researchers, and such groups may have been informed to some extent by our understanding of the research topic. Fourth, we focused on one specific CQI program (ie, SafetyNET-Rx), located in one regulatory jurisdiction (ie, Nova Scotia). Future research is therefore needed to address these limitations and generalize the findings by, for example, administering a survey of a larger group of stakeholders and at different stages of the innovation (ie, CQI program) diffusion process. Despite these limitations, with pharmacies increasingly under pressure to adopt formal CQI programs, this research provides pharmacy managers with a number of issues to be aware of as they undertake such initiatives, as well as potential ways that such issues may be addressed. Acknowledgments The authors thank the Nova Scotia College of Pharmacists and Institute for Safe Medication Practices Canada for their support, as well as Christopher Hillier, Brett Jackson, Mia Mahaffey, and Jeffrey Taylor for assisting with various data collection, data analysis, and editing activities. This work was supported by the Nova Scotia Health Research Foundation Collaborative Health Research Project Grant Program (PSOProject-2009-5786).

4.

5.

6.

7. 8.

9. 10.

11.

12.

13.

14. 15.

16.

References 1. Patel A. Tragic medication errors result in accidental abortions and premature birth. Available at: http:// abcnews.go.com/Blotter/story?id¼8383062. Accessed 10/07/11. 2. Two nurses charged in medication incidents involving children’s hospital. Available at: http://www.kirotv. com/news/27846231/detail.html. Accessed 10/07/11. 3. Nova Scotia College of Pharmacists. Standards of Practice for Quality Assurance Programs in Community Pharmacies 2010. Available at: http://www. nspharmacists.ca/standards/documents/Continuous

17.

18.

19.

QualityAssuranceProgramsinCommunityPharmacies January2010_000.pdf. Accessed 10/07/11. Ashcroft DM, Quinlan P, Blenkinsopp A. Prospective study of incidence, nature and causes of dispensing errors in community pharmacies. Pharmacoepidemiol Drug Saf 2005;14:327–332. Wakefield BJ, Blegen MA, Uden-Holman T, Vaughn T, Chrischilles E, Wakefield DS. Organizational culture, continuous quality improvement, and medication administration error reporting. Am J Med Qual 2001;16:128–134. National Association of Boards of Pharmacy. Survey of pharmacy and law. Available at: http://www.usc. edu/hsc/nml/assets/pdf/2010%2520Final%2520Survey %2520no%2520letter.pdf. Accessed 10/07/11. Yin R. Case Study Research: Design and Methods. Thousand Oaks, CA: Sage; 2004. Ibeh KIN, Ibrahim E, Panayides PM. International market success among smaller agri-food companies: some case study evidence. International Journal of Entrepreneurial Behaviour and Research 2006;12: 85–104. Braun V, Clarke E. Using thematic analysis in psychology. Qual Res Psychol 2006;3:77–101. Handler SM, Nace DA, Studenski SA, Fridsma DB. Medication error reporting in long term care. Am J Geriatr Pharmacother 2004;2:190–196. Mandt I, Horn AM, Ekedahl A, Granas AG. Community pharmacists’ prescription intervention practicesdexploring variations in practice in Norwegian pharmacies. Res Social Adm Pharm 2010;6: 6–17. Davis FD. Perceived usefulness, perceived ease of use, and user acceptance of information technology. MISQ 1989;13:319–340. Mustonen-Ollila E, Lyytinen K. Why organizations adopt information system process innovations: a longitudinal study using diffusion of innovation theory. Inform Syst J 2003;13:275–297. Sanson-Fisher RW. Diffusion of innovation theory for clinical change. Med J Aust 2004;180:55–56. Novek J. Hospital pharmacy automation: collective mobility or collective control? Soc Sci Med 2000;51: 491–503. Ashcroft DM, Morecroft C, Parker D, et al. Likelihood of reporting adverse events in community pharmacy: an experimental study. Qual Saf Health Care 2006;15:48–52. Knudsen P, Herborg H, Mortensen AR, Knudsen M, Hellebek A. Preventing medication errors in community pharmacy: frequency and seriousness of medication errors. Qual Saf Health Care 2007;16:291–296. Bell HM, McElnay JC, Hughes CM. A self-reported work sampling study in community pharmacy practice. Pharm World Sci 1999;21:210–216. Miller MR, Clark JS, Lehmann CU. Computer based medication error reporting: insights and implications. Qual Saf Health Care 2006;15:208–213.