This study explores the relationship between safety climate and the reporting of dispensing errors in a national sample of community pharmacies in Sweden. An association between safety climate and errors has been established in other parts of health care [18, 19]. No significant relationship between reported dispensing errors in Swedish community pharmacies and Safety Culture, after controlling for variability in respondent and pharmacy demographics, was found. The presence of an unusually strong safety culture in these community pharmacies, as compared to other health care settings in the USA , has been previously reported. An explanation for this strong culture might be the fact that the National Corporation of Pharmacies for a long time put great effort into quality management and worked intensively on initiating measures for continuous improvements . This included elements like definite guidelines; i.e. standard operation procedures for the dispensing process and other processes. Various indicators were used to assess quality in pharmacies and for instance all staff went through quality education around 2000. Thus it could be assumed that good quality awareness, with a ruling influence on safety issues in pharmacies, was present and impacted the outcome of this survey.
Thus one possible explanation for the lack of association is that a ceiling effect may have reduced the possibility to discriminate between pharmacies. Anecdotally, recent work at Johns Hopkins Hospital suggests that the more mature a reporting system is, the more the relationship between SAQ dimensions and error reporting declines . Perhaps it is the case that, as staff build confidence and trust around safety standards and reporting procedures, the predictive power of safety culture as a proxy for “safety-related trust” is diminished. The system becomes a natural part of the work place and therefore only an increasingly weak relationship with reported dispensing errors would be found, which could be one explanation to the pattern of results found in the current study. The differences between settings in this study compared to those in the other studies; i.e. hospital units vs. pharmacies, as well as difference in instruments used for assessing safety climate and error-reporting systems used, also make direct comparisons difficult. As our study is larger than the other studies, lack of power is however not likely to explain the lack of association, if there is one.
The SAQ dimension Teamwork Climate has also been demonstrated to be strong in Swedish community pharmacies,  and presumed to reveal prevalence of good co-operation and respect among staff [39, 40]. As already noted, no relationship was found with dispensing errors in this study, after controlling for demographic variables. Again, a ceiling effect might partially explain this.
The only Safety Attitudes Questionnaire domain that was significantly, positively, correlated with dispensing errors, after controlling for demographics, was Stress Recognition. In SAQ this dimension is an indicator of individual attitudes rather than of group attitude, since the dimension, unlike all other dimensions, is dominated by items referring to “I” rather than “we” (see Additional file 1). It might be questioned whether there is a place for a dimension primarily assessing individual’s self-awareness within the framework of the presumed collective safety climate area. The within-unit and between-unit analysis has however ensured that this variable performs satisfactorily at group level, although considerably poorer than the other dimensions. When staff members in a pharmacy experience dispensing errors, the awareness of the risk of errors may increase, with increased stress recognition among staff as one possible outcome. This may explain the counterintuitive relationship between stress recognition and dispensing errors, where more self aware staff members, with regard to how they behave under pressure, is associated with more reported dispensing errors. This seems to be contrary to prior research linking higher stress recognition to better performance in commercial aviation pilots , but further investigation is warranted. In an American study, safety climate was negatively related to incident reporting volume, while stress recognition was independently positively related to incident reporting volume, which correlates with our findings  The difference between that study, and the current study, is that this national sample of community pharmacies included far more demographic variables, which were not controlled for in the American study. If controlling for demographic variables diminishes the predictive power of safety culture over incident reporting, then the current study has identified the importance of controlling for respondent and site demographic variables. It is possible that the size of this nation-wide study was so large, and the number of demographic variables was so comprehensive, that few other studies (to date) into incident reporting have the ability to attempt such an analysis.
Relationships were found between high levels of dispensing errors and high numbers of dispensed prescription items and employees, respectively. This might be an indication of the fact that the bigger the pharmacy, in terms of number of employees and prescription volumes the busier the surroundings are. It might become difficult to convey information on safety issues and prescriptions and have informative communication between colleagues; misunderstandings might be more common. It will also become harder to get to know your colleagues .
A relationship was also found between age and dispensing errors; the higher the mean age in a pharmacy is, the lower the number of dispensing errors is. Seniority has been found to bring about experience . The senior staff might make fewer errors, as they are more experienced, know the pitfalls and can avoid them. Who makes most errors – the experienced staff or the more junior staff? This question has been evaluated by O’Shea  in a literature review, but the answer was inconclusive.
In the first correlation analysis a number of relationships regarding demographic diversity were found and significant relations were found between reported errors and education, birth country as well as education country. The only remaining relationships, after having controlled for covariates in the regression analysis were education background diversity and an association between having a heterogeneous staff with regard to educational background (non-Swedish/Swedish) and dispensing errors. The more multifaceted the educational background is, the more errors are reported. Misunderstandings between different cultural groups of health care personnel have been reported in Sweden . Cultural differences and language barriers in pharmacies might lead to misunderstandings and misinterpretations, resulting in more errors. A non-native health-care staff might also experience a more difficult working situation in relation to patients, due to cultural differences  and communication problems  which might increase the risk for errors. It is important, however, to remember that these problems are balanced by the advantages of having multicultural competence at the working site and the degree of advantages depends largely on leadership . This exploration suggests a possible relationship between demographic diversity variables and reported errors. The theory behind demographic diversity is complex  and an in-depth analysis might be worthwhile.
A negative association was found between the numbers of dispensing errors and response rate. A high response rate on a questionnaire about safety attitudes might be a measure of the staff’s attentiveness to these issues. If so, a high response rate might be an indicator of responsible behaviour, which in turn might be associated with deliberate and careful dispensing behaviour.
A high agreement between reported errors and actual errors is assumed, based on the fact that the reporting system is relatively mature . The Swedish reporting system is now over 10 years old and administrative procedures are in place. There is a clear-cut definition of a dispensing error and specific guidelines regarding handling of errors. Such clarity is considered to positively incentivize reporting behaviour [12, 14]. Several measurements have been made over the years, which has put a focus on dispensing errors in the National Corporation of Pharmacies, e.g. the introduction of an intervention, targeted to reduce specific errors . Feed-back has been provided to the users on a regular basis over the years. Other studies have demonstrated that when safety climate is very positive (i.e. safety “trust” is high), the reported number of errors is closer to the actual number of errors . Experiences of previous handling of errors influence the way staff behave, i.e. a mature and non-punitive approach to errors will result in a higher degree of detecting and reporting of errors.