Evaluating Patient Safety Culture in Iraqi Community Pharmacies

Patient safety is the main issue in health care organization, the agency for Healthcare Research and Quality defines it as, “freedom from accidental or preventable injuries produced by medical care. Thus, practices or interventions that improve patient safety are those that reduce the occurrence of preventable adverse events”. The purpose of this study was to evaluate Iraqi pharmacist perception about the culture of patient safety. As well as estimate whether safety is a principal issue in their pharmaceutical practice. This study was carried out on 435 pharmacists who are working in community pharmacies in various Iraqi provinces. A survey was distributed via the internet during the period from May to June 2020. A community pharmacy questionnaire was used to evaluate the awareness of pharmacists regarding the culture of patient safety. A result of this study showed that the patient counseling field was the most positive one among the studied domains with score 68.8% of positive awareness and 70.4% of the pharmacists indicated that they inform patients with needed information about their new prescriptions. In contrast, staffing and work pressure scored the lowest positive response (36.55%). Although 66.7% of the participants stated they have the appropriate number of staff in their pharmacies to deal with the workload.


Introduction
Indeed, Iraqi society considers pharmacist as a trusted source for medical advice besides the traditional role of community pharmacy in medication supply (1) . Community pharmacies recognized internationally as the most easily accessible and cost-effective sites for introducing healthcare services (2) . Pharmacists working in the community pharmacies can considerably add to national work aimed for the enhancement of patients care and quality of life (3) . Since pharmacists are usually responsible for optimizing drug therapy and preventing medication errors, an inspection of pharmacists' safety culture in various settings can provide insight into their understanding and help identify weakness domains in order to improve them (4) . A public concern is globally raising around patient safety issue in various health care settings (5) . Institute of Medicine (IOM) has publishing its first statement about patient safety and patient hurt "To Err Is Human: Building a Safer Health System", which has highlight the topic of safety as well as preventable medical errors cost at the forefront of healthcare practice and the national conversation (6)(7) . The culture of patient safety is explained as "the beliefs, values, and norms regarding how members of an organization should behave and includes policies, procedures, and processes to improve quality and safety" (8) .
It is very important to establish and maintain a solid base of safety culture which identified as an essential constituent of using medication safely (8) . Despite all efforts to minimize the occurrence of patient hurt, actually every 20 patients there was one patient subjected to a preventable injury (9) . Worldwide, medication errors are considered a problem which requires serious efforts (10) . It is explained as "any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer" (11) . The occurrence of such errors were documented as a pricey issue for health care organization in addition to its negative influence on patients and health care staff (12) .
Drug dispensing is considered as the main task in pharmaceutical practice, which in turn make it an important source of such errors, thus it can form a persistent risk to the safety of the patient (13) . One of the notable reasons for errors in pharmacy practice are distractions and interruptions (14) . In its recent issue of questionnaires about the culture of safety the American agency for Healthcare Research and Quality (AHRQ) published the Pharmacy Survey on Patient Safety Culture, which aimed to rising consciousness regarding safety culture assessment in community pharmacy (15) . Accordingly, the purpose of this study was doing to evaluate Iraqi pharmacist's perceptions who are working in community pharmacies about the culture of patient safety. As well as, it estimates whether safety is a primary issue in their practice.

Participants
This study was a cross-sectional one that involved 435 pharmacists working in community pharmacies in many Iraqi provinces, from May to June 2020. The number of males participants was 195 (44.8%) while the number of females was 240 (55.2%).

Inclusion criteria
Pharmacists who are working in community pharmacies Exclusion criteria Other workers in community pharmacy such as pharmacist assistant

Method The questionnaires
Assessing the culture of patient safety using precise comprehensive questionnaires designed for community pharmacy workers is known as the Pharmacy Survey on Patient Safety Culture (16)(17) . The survey used with some modifications to suite Iraqi community pharmacy system (for example there is no documentations for mistakes in Iraqi pharmacies). The survey form contains 36 items assembled into three-part which is working in this pharmacy, communication and work pace, the last one patient safety and response to mistakes. These three part assessed 11 important fields of patient safety culture (18) . Also, contains an overall rating question section and background questions about participant additional items were added to this section. It is distributed in the English language. The survey items were previously validated (pilot study). Five-point scale was designated for agreement or frequency type of answers was applied for responses measuring.

Administration of the questionnaires
It was an electronic survey using google form. The survey was distributed via the internet in professional groups of Iraqi pharmacists and as a mixed form (hardware and software) in Al-Qādisiyyah provinces to the pharmacists working in community pharmacies. The participation was optional, anonymous and no incentive was offered to the participants.

Statistical analysis
Analysis was done using Statistical Package for Social Science (SPSS, version 22, IBM, New York, USA). Descriptive statistics (means, standards deviations, frequencies, and percentages) of the participants were calculated. Agreement responses which include "strongly agree", "agree", "most of the time", and "always" were combined to "positive" responses, while disagreement covers the following responses "strongly disagree" and "disagree" "never" and "rarely" was compiled into "negative" response. "Don't know" were excepted from answers. Measurement of dimensions through calculations of positive responses means, for negatively worded items the negative answers combined to confirm dimensions positivity. Participants categorized according to their duration of working in the pharmacy into three groups: the first group has experience up to one year, the second group with 1-3 years of working, and the last group with longer duration of working more than three years of experience in the pharmacy. Kruskal-Wallis test (nonparametric test used for skewed distribution data) was used to measure the difference among participants regarding measured items according to working years

Results
The study recruited 435 pharmacists with an average age of 30.11 years. From 16 Iraqi provinces, Baghdad (31%) and Al-Qādisiyyah (30.3%) the most common participating provinces where showed in (Table1).  Positive response to other domains ranged from 47.4% to 61.6%. The overall positive perception of safety between pharmacists was 61.6%. The statement "the staff treat each other with respect" scored high agreement response with an average of 3.82 (± 1.15), in other word 74.2% of the pharmacists reported positive response about the statement. "This pharmacy places more emphasis on sales than on patient safety" 66.9 19.3 9.9 "This pharmacy is good at preventing mistakes". 69.7 16.6 11.5 "The way we do things in this pharmacy reflects a strong focus on patient safety"

Assessment of pharmacist according to the experience years in pharmacy
Regarding work in this pharmacy, participants assessed according to experience years in the pharmacy, significant finding (P-value < 0.5) reported in this section. In other word, pharmacists with experience longer than three years, state pharmacy members were more aware of their task than other groups of participants as showed in (Table 4). Another part the communication and work pace. Pharmacists who worked in pharmacy longer than three years demonstrated significant difference (P-value < 0.5) regarding interruptions/distractions in their pharmacies as compared to those who worked less than three years as showed in (Table 5).

Overall rating of pharmacists to their pharmacy regarding patient safety
The participating pharmacists rated the patient safety standards of their pharmacies as good with average 3.38 (±0.9). More specifically, 82.3% of pharmacists rated their pharmacy patient safety standards between good and excellent as shown in the figure below.

Discussion
Culture of safety has grown to have a significant issue in research in the subject of patient safety and there is a developing consideration to maintain efficient interventions to enhance safety (19) Measurement of safety culture is essential because the organizational culture as well as team attitudes have been shown to affect patient outcomes and may work as tools to observe progress (20) .Result from this study showed the highest agreement and positivity in the patient counseling field which is similar to the result of study conducted in Wisconson in the United States of America (Aboneh et al 2020) (16) .
Community pharmacists have a principal role in effectively use of medication ,enhancing patient outcomes, as well as avoiding misuse of medication (21) . During the medication course, it was verified that self-administration was complicated and susceptible to many errors (22) .
The efficient communication among patients and pharmacists is an essential factor in affecting the quality of patient counseling, and has an impact on healthcare outcomes, mutual trust, and patient satisfaction, (23) . Teamwork scored second place in this study which is a similar findings to the result of study conducted in Wisconson in the United States of America (Aboneh et al 2020) (16) .
Regarding pharmacy practice, teamwork is essential for improving patient care. (24) . Favorable interaction between pharmacy members, can efficiently improve work processes and deal with unaccepted events that may occur during the daily work (25) . Constantly pharmacy team can communicate with patients and realize the causes that influence patients' ability to control their chronic disorders (26) . The field of organizational learning-continuous improvements recorded in third place in word of agreement response . Many researches show that medication errors attributed to different causes can be categorized into personal and organizational (27) .
Persistent quality improvement focused on organization work process to figure out the source of errors and optimize patient safety (28) . In the health system ,culture of blame is an essential cause of unaccepted medical errors (29) . Trust in the organization is a critical factor for establishing the culture of safety (30) . Regarding the result of study staffing work pressure domain recorded lowest positive response. This is similar to study conducted in community pharmacies in Abu Dhabi in the United Arab Emirates (Alslubi et al 2019) (31) . It has also shown similarity to a study conducted in Malaysia( Sivanandy et al's 2016) (32) .And the same results were found in the previous Wisconson study (Aboneh et al study 2020) (16) .In this study, 33.8% (around one-third) of the participant report their pharmacies to have interruptions which can influence workflow. Despite that 66.7% of the participants have stated they have the appropriate number of staff in their pharmacies to deal with the workload, workrelated pressure has an adverse influence on quality associated event, that reach to patient or those stopped before dispensing (33) .
An additional suitable solution is training technicians who might able to reduce pharmacists dispensing workload, (34) .There was a significant difference between pharmacist according to the experience year in pharmacy and distraction and interruptions. In other words, with a longer period of work in the pharmacy, interruptions of healthcare provider was a more considerable workload and interfere with workflow (35) . Most of the pharmacists (n=211) rate their pharmacies good about the standers of safety in their practice, which is similar to the result of study previously mentioned Wisconson study (Aboneh et al study 2020) were (92 %) of participant rate their pharmacies standers as good (16).

Conclusion
Iraqi community pharmacists have shown patient safety priority orientation, and there was a notable collaboration and communication between pharmacy workers. Also, they show an interest in the pharmacy environment and workflow. T. Using Failure mode and effects analysis to reduce patient safety risks related to the dispensing process in the community