Table 4 Risk factors identified through the content analysis

Social, regulatory and external environmental factors (N = 6, 10.3%)

Policy with potential financial incentives

(2, 3.45%)

The dispensing fee policies incentivised improper claims and the pursuit of unwarranted financial gains, particularly noticeable among profit-driven pharmacists.

“It was the PCC’s contention that the close control regime potentially provided a significant financial incentive for a pharmacist to dispense on a close control basis.” (HPDT26&27)

Media pressure

(1, 1.72%)

As a result of a prior error at the pharmacy, this situation escalated the pharmacist’s stress and subsequently led to dispensing errors.

“It was stated that the pharmacy had been under intense media pressure due to prior errors, (these occurring before [the practitioner] was employed by the pharmacy)…It was acknowledged that the pharmacy in this case had been the subject of media attention.” (HPDT03)

Insufficient certification system

(1, 1.72%)

The return-to-practice application system lacked a provision for the practitioner to accurately indicate the date of her practice resumption, which ultimately led to the engagement in forgery misconduct.

“A complicating factor in this case is that although [the practitioner] went online to complete the application for her APC, that application did not specifically ask her to declare that she was currently practising the profession as required under s 26(2)(a) of the Act. The “Return to Practice” form does not strictly meet these requirements.

Although these provisions do not excuse [the practitioner] from her actions of submitting inaccurate information on the “Return to Practice” form, they do in part demonstrate the difficulty she had in reflecting her circumstances at that time when completing the form online.” (HPDT55)

Low socio-economic environment

(1, 1.72%)

The challenging socio-economic context led the pharmacist to rely on a complex and unreliable computer system, resulting in a criminal conviction for document misuse aimed at financial gain due to dealing with disorganised and non-compliant patients.

“[The practitioner] described his pharmacy as being in a low socio-economic area with a high percentage of turnover coming from prescriptions and many clients with serious medical problems on Community Service Cards. Many of them were highly disorganised and non-compliant with taking their medicines.”

[The practitioner] described the fact that there had been difficulties where, “…patients who were unable to receive dispensing of repeats because they were a day or so over the time limits for the funded dispensing of those repeats became irate and threatening.”…He therefore had his computer system generate a report of the repeat medication prescriptions which were close to expiry date…This system became more sophisticated with time with the medicines not being dispensed in later months but simply labels prepared. Towards the end of the period when [the practitioner] was running the system the prescriptions were simply put through the computer system and claimed from the government without either the labels or prescriptions being made up. If the patient came in to the pharmacy then the medicines were dispensed as required. (HPDT04)

Insufficient warning from authority

(1, 1.72%)

The absence of warnings from regulatory bodies regarding past investigations led to a lack of awareness among pharmacists regarding the seriousness of the issue, contributing to misconduct in medication provision.

“[The practitioner] said that he believed that because Medsafe, HealthPac, and the Medical Association representatives had and were continuing to investigate [the doctor], he thought that those “higher authorities” had whatever situation they were investigating under control. As no instruction to discontinue dispensing had been issued, that suggested to him that everything regarding [the doctor]’s prescribing of Sudomyl had been investigated and no other steps were required.” (HPDT09)

Systematic, organisational and practical factors in the pharmacy (N = 28, 48.28%)

Busyness, heavy workload or distraction

(15, 25.96%)

In a busy and distracting practical environment, practitioners found it challenging to maintain proper standards, leading to reduced attention to detail, increased stress, depression, and drug use, ultimately heightening the risk of errors.

“There were times when [the practitioner] worked at the Pharmacy for 13.5 hours. Although the Tribunal is not asked to make any comment on the sensibility of this, it would certainly have meant that he would be tired from time to time and risks of mistakes increase.” (HPDT47)

“[The practitioner]’s explanation for not starting an incident report, that he was “distracted” (by high volume checking and dispensing of prescriptions and medico-packs)…” (HPDT39)

Illegal, unethical or irresponsible employer

(5, 8.62%)

Practitioners sometimes engage in wrongful behaviour by following illegal or unethical orders from their employers. Additionally, an irresponsible employer failing to ensure the practitioner had a current APC also contributed to misconduct.

“It is not for the Tribunal to make any finding against the employer; but the Tribunal notes that it is disappointing that the employer did not apparently take any responsibility to ensure that [the practitioner], while in that employment, had a current APC.” (HPDT34)

“This evidence related of course to the evidence that the owner of Birkenhead Avenue Pharmacy, [the owner], was apparently acting in a way which raised such concerns, and the Practitioner’s position in the correspondence that it was [the owner]’s practices that he was implementing.” (HPDT43)

Inadequate pharmacy system

(3, 5.17%)

Inadequate maintenance of repeat prescription records, absence of patient scripts, errors in data entry, and breakdowns in communication directly impeded the efficiency and accuracy of pharmacist practice.

“It would appear that the system which was in place at the relevant time was not programmed adequately to pick up such discrepancies. Such systems should be in place as referred to in [the pharmacist advisor]’s evidence (above) would be further enhanced by being able to check with the patient directly.” (HPDT09)

Unfavourable workplace culture

(3, 5.17%)

Strained work culture and incidents of bullying induced pressure on the practitioner, undermining their confidence in professionalism, causing health deterioration and professional impairment.

“[The Practitioner] explained that, in addition to this pressure, he had lost confidence in his professionalism and, on reflection, acknowledges that he was in poor health. He stated that the nature of the working situation was, for him, basically a ‘toxic’ one.” (HPDT10)

Previous errors in the pharmacy

(1, 1.72%)

As the root cause of the media pressure, prior pharmacy errors indirectly played a role in fostering pharmacist misconduct, as depicted in the aforementioned example.

“It was submitted for [the practitioner] that the background to the error was relevant. It was stated that the pharmacy had been under intense media pressure due to prior errors, (these occurring before [the practitioner] was employed by the pharmacy).” (HPDT03)

Pharmacist individual factors (N = 16, 27.6%)

Health impairment

(9, 15.52%)

Health impairment, including physical illness, mental health challenges, and substance abuse, often originates from personal life stressors or suboptimal work environments, indirectly contributing to pharmacist misconduct behaviours.

“[The Practitioner] reported to [The Psychiatrist] that she felt very stressed and low in mood and had become suicidal, therefore she wrote a number of prescriptions with a plan to overdose. [The psychiatrist]’ opinion was that [The Practitioner]’s ‘actions in writing the prescriptions were directly linked with her mental illness’.” (HPDT44)

“[The Practitioner] had been ‘under considerable stress and in that state of anxiety, completed the online form for registration incorrectly.” (HPDT55)

Life stress or challenge

(7, 12.07%)

Life stressors and challenges primarily act as predisposing factors for pharmacist health issues, indirectly influencing pharmacist misconduct behaviours.

“[The Practitioner] said his position was not helped by the fact that he does not have any family or other support network in New Zealand, and he described this as having resulted in a vicious cycle of depression and drug use.” (HPDT31)

“My fault may be my empathetic nature to my family, friends, staff and customers. I was completely consumed by my friend’s impending death that I overlooked the requirement to have my application to the Pharmacy Council…” (HPDT37)

Opposition to authority or rule

(2, 3.45%)

Pharmacists opposed to the Pharmaceutical Society or the Standard Operating Procedures (SOPs) resulted in their failure to adhere to established ethics and professional standards.

“[The Practitioner] reiterated that SOPs were not appropriate and gave examples of where he thought his own methods would suffice. He said, for example that he would visually inspect starting materials…” (HPDT18)

“A key element of the Practitioner’s evidence involved explaining his long-standing differences with the Pharmaceutical Society of New Zealand. The reasons for these differences are unimportant. The Tribunal accepts that the Practitioner had a rooted objection to becoming a member of the Pharmaceutical Society. In his evidence, the Practitioner described himself as a “conscientious objector”. There is room for different views as to whether that description of his position is apt. “ (HPDT36)