A qualitative systematic review on the application of the normalization of deviance phenomenon within high-risk industries.

INTRODUCTION: The concept of normalization of deviance describes the gradual acceptance of deviant observations and practices. It is founded upon the gradual desensitization to risk experienced by individuals or groups who recurrently deviate from standard operating procedures without encountering negative consequences. Since its inception, normalization of deviance has seen extensive, but segmented, application across numerous high-risk industrial contexts. The current paper describes a systematic review of the existing literature on the topic of normalization of deviance within high-risk industrial settings. METHOD: Four major databases were searched in order to identify relevant academic literature, with 33 academic papers meeting all inclusion criteria. Directed content analysis was used to analyze the texts. RESULTS: Based on the review, an initial conceptual framework was developed to encapsulate identified themes and their interactions; key themes linked to the normalization of deviance included risk normalization, production pressure, culture, and a lack of negative consequences. CONCLUSIONS: While preliminary, the present framework offers relevant insights into the phenomenon that may help guide future analysis using primary data sources and aid in the development of intervention methods. PRACTICAL APPLICATIONS: Normalization of deviance is an insidious phenomenon that has been noted in several high-profile disasters across a variety of industrial settings. A number of organizational factors allow for and/or propagate this process, and as such, the phenomenon should be considered as an aspect of safety evaluations and interventions.

The development of the helicopter non-technical skills (HeliNOTS) behavioural marker systems.

Behavioural marker systems (observational frameworks geared towards the assessment of non-technical skills by way of behavioural markers) exist across a variety of high-risk occupations, however, no identifiable system currently exists developed from rotary operative data. In this study, discussion groups (n = 9) were undertaken with subject matter experts (n = 20)-including pilots and technical crew operating across search and rescue and offshore transport environments-with the objective of identifying role-specific behavioural markers. Systems were reviewed on an iterative basis by the academic team and received final reviews by additional subject matter experts (n = 6). Two behavioural marker systems were constructed: HeliNOTS (O) for offshore transport pilots and HeliNOTS (SAR) for search and rescue crews; each with domain-specific behavioural markers. Both represent a significant step towards a nuanced approach to training and assessment of helicopter flight crews' non-technical skills and are the first publicly available systems tailored to these distinct mission types.Practitioner summary: There is no publicly available behavioural marker system based on data from rotary operatives. Across this study, two prototype systems were developed: HeliNOTS (SAR) for helicopter search and rescue, and HeliNOTS (O) for helicopter offshore transport. Both HeliNOTS systems represent a nuanced approach towards rotary CRM training and assessment.

Perceived Hospital Stress, Severe Acute Respiratory Syndrome Coronavirus 2 Activity, and Care Process Temporal Variance During the COVID-19 Pandemic.

OBJECTIVES: The COVID-19 pandemic threatened standard hospital operations. We sought to understand how this stress was perceived and manifested within individual hospitals and in relation to local viral activity. DESIGN: Prospective weekly hospital stress survey, November 2020-June 2022. SETTING: Society of Critical Care Medicine's Discovery Severe Acute Respiratory Infection-Preparedness multicenter cohort study. SUBJECTS: Thirteen hospitals across seven U.S. health systems. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We analyzed 839 hospital-weeks of data over 85 pandemic weeks and five viral surges. Perceived overall hospital, ICU, and emergency department (ED) stress due to severe acute respiratory infection patients during the pandemic were reported by a mean of 43% ( sd , 36%), 32% (30%), and 14% (22%) of hospitals per week, respectively, and perceived care deviations in a mean of 36% (33%). Overall hospital stress was highly correlated with ICU stress (ρ = 0.82; p < 0.0001) but only moderately correlated with ED stress (ρ = 0.52; p < 0.0001). A county increase in 10 severe acute respiratory syndrome coronavirus 2 cases per 100,000 residents was associated with an increase in the odds of overall hospital, ICU, and ED stress by 9% (95% CI, 5-12%), 7% (3-10%), and 4% (2-6%), respectively. During the Delta variant surge, overall hospital stress persisted for a median of 11.5 weeks (interquartile range, 9-14 wk) after local case peak. ICU stress had a similar pattern of resolution (median 11 wk [6-14 wk] after local case peak; p = 0.59) while the resolution of ED stress (median 6 wk [5-6 wk] after local case peak; p = 0.003) was earlier. There was a similar but attenuated pattern during the Omicron BA.1 subvariant surge. CONCLUSIONS: During the COVID-19 pandemic, perceived care deviations were common and potentially avoidable patient harm was rare. Perceived hospital stress persisted for weeks after surges peaked.

Consequences and coping: Investigating client, co-worker and senior colleague incivility within veterinary practice.

BACKGROUND: Workplace incivility is a workplace stressor with varying effects according to the status of the target and instigator. This study sought to examine veterinary staff's experiences of incivility from clients, co-workers and senior colleagues. METHOD: An online mixed-measures survey gathered data from UK veterinary staff (n = 252, primarily veterinarians and nurses). Quantitative scales were used to collect data on incivility frequency, burnout, mental health, job satisfaction, turnover intention and key coping responses. Qualitative data expanded on preferred coping strategies. RESULTS: The impact of uncivil behaviour varied according to the source of the incivility and the status of the target. Senior colleague incivility predicted veterinarian turnover intention, whereas client incivility predicted burnout. Similarly, senior colleague incivility predicted job satisfaction for veterinary nurses. Seeking support was the most frequently reported coping strategy. The qualitative data illustrated strategies focused on calming the situation and management of self. LIMITATIONS: The data are based on self-reports and are subject to social desirability bias. The sample is limited to UK veterinary staff. CONCLUSION: Veterinary staff are at risk of experiencing incivility, with varying impacts across job roles and incivility sources. A proactive system approach to incivility is recommended, encompassing support and procedural changes.

'No-one else wears one:' Exploring farmer attitudes towards All-Terrain Vehicle helmets using the COM-B model.

INTRODUCTION: All-Terrain Vehicles (ATV) are a popular piece of farming machinery but are linked to many fatalities and injuries every year. Despite evidence that ATV helmets reduce the risk of serious or fatal injury, research suggests that few farmers wear them. The aim of this study was to explore farmer attitudes toward ATV helmets, using the COM-B model as a framework to identify key barriers and enablers of helmet use and suggest potential interventions to increase helmet use in agriculture. METHODS: A mixed-methods online survey featuring quantitative and qualitative questions was used to explore key attitudinal factors relevant to farmer helmet wearing. A total of 211 UK and Irish farmers were recruited, including farm owners, managers, workers, and contractors. RESULTS: Personal exemption from risk, emotional benefits, cognitive barriers, and guideline prompts were all found to be significant predictors of farmer helmet wearing. Key categories within the qualitative data indicated that helmet properties, risk perception, farming culture, and the farming environment could all function as barriers to helmet wearing. Suggested enablers of helmet use included increasing helmet availability and enhancing awareness of the consequences of ATV accidents. CONCLUSIONS: The key barriers and enablers presented within this paper highlight the relevance of capability (helmet design, time pressure), opportunity (social norms), and motivation (perceived control of risk) when considering farmer helmet wearing behaviors. In order to encourage farmers to wear helmets it will be necessary to design specific interventions using the behavior change wheel. PRACTICAL APPLICATIONS: Key interventions to prompt helmet use include the inclusion of more cues to prompt helmet wearing (e.g., stickers on the ATV), enhanced training and education, and modelling (e.g., key farming figures shown to wear helmets in the media).

Watch Out for the Bull! Farmer Risk Perception and Decision-Making in Livestock Handling Scenarios.

Livestock cause many fatal and non-fatal agricultural accidents. It is crucial to understand how farmers perceive and manage different risks associated with livestock handling to devise better solutions for accident reduction. The current study investigated farmers' perception and management of four types of livestock handling risks related to self, animal, environment, and equipment. Additionally, farmers' and agricultural stakeholders' perspectives were compared.Two samples comprising 56 farmers and 55 stakeholders from the UK and Ireland completed the online study. Participants were presented with eight short livestock handling vignettes, two per risk type, and were asked to decide whether they would proceed with the task, to report their reasoning, and to detail their risk management strategies. Likert-scale responses across scenarios were compared. Thematic analysis was used to identify qualitative data patterns.Stress and fatigue were perceived as low risk by both samples based on quantitative and qualitative results. The thematic analysis revealed that risk was evaluated in terms of broader aspects, including animal welfare and duty. Participants reported the use of cognitive non-technical skills when mitigating risks associated with handling livestock alone.By changing safety messages to capture farmer priorities, agricultural organisations could encourage risk avoidance, especially in situations involving stress or fatigue. Furthermore, the cognitive non-technical skills identified could be trained within existing courses for farmers.

Ruminating on rudeness: Exploring veterinarians' experiences of client incivility.

BACKGROUND: Interactions with clients have been identified as a key potential stressor within veterinary practice. However, there is a lack of research investigating the experience, and impact, of specific behaviours, such as incivility. The current study aimed to address this literature gap by investigating veterinarian perceptions of client rudeness. METHOD: Telephone interviews (n = 18) were used to gather qualitative data regarding veterinarian perceptions of client rudeness. This encompassed description of an uncivil interaction, potential causes of incivility, the impact on the veterinarian and coping strategies. RESULTS: The results indicate that veterinarians are exposed to a range of rude behaviours from clients, with suggested causal attributions spanning financial concerns, stress and worry. Adverse consequences associated with uncivil interactions included increased stress, mental health impacts and withdrawal from clients. Responses to incivility encompassed proactive pre-planning, empathy and clear communication. Support from colleagues was important to enable reflection and coping, alongside individual strategies, such as self-care. CONCLUSION: Client incivility has the potential to adversely impact veterinarians. Appraisal of potential external causes for rudeness could facilitate constructive responses to client incivility and support coping. This should be combined with emotional support from colleagues to mitigate any negative consequences following uncivil client interactions.

Phase II Study of Eribulin Mesylate Administered Biweekly in Patients With Human Epidermal Growth Factor Receptor-2-negative Metastatic Breast Cancer.

BACKGROUND: Patients with human epidermal growth factor receptor-2-negative metastatic breast cancer (MBC), whose disease progressed on prior chemotherapy, have a poor prognosis. Eribulin, a microtubule dynamics inhibitor, extends overall survival in previously treated MBC. The most common adverse event associated with eribulin is neutropenia, which may result in dose interruptions or reductions. A modified biweekly dosing schedule of eribulin was assessed for efficacy as well as improvements in hematologic toxicity. PATIENTS AND METHODS: In this open-label, single-arm, multicenter, phase II study, previously treated (2-5 chemotherapy regimens for metastatic disease) patients with human epidermal growth factor receptor-2-negative MBC received intravenous eribulin 1.4 mg/m2 over 2 to 5 minutes on days 1 and 15 of each 28-day cycle. The primary study endpoints were objective response rate (ORR; complete response [CR] + partial responses [PR]) and disease control rate (DCR; CR + PR + stable disease [SD]). RESULTS: Among 58 treated patients, the ORR was 12% (95% confidence interval [CI], 5%-24%), DCR (CR, n = 1; PR, n = 6; SD, n = 30) was 65%, and the median progression-free survival was 3.6 months (95% CI, 2.9-4.1 months). Grade 3 or 4 neutropenia was 31%; 50% of all patients, and 78% of patients with neutropenia (all grades), received hematopoietic growth-factor support. CONCLUSION: The efficacy and safety results obtained with a biweekly eribulin schedule in this phase II trial appear similar to those associated with the approved eribulin schedule (1.4 mg/m2 on days 1 and 8 of a 21-day cycle) reported in the EMBRACE study.

Part and Parcel: A Qualitative Interview Study Examining the Experience of Client Rudeness by Mental Health Workers.

Considerable research has demonstrated that workplace rudeness can have a variety of negative consequences. However, although research has examined the impact of patient aggression, no research has examined patient or client rudeness towards those who work in mental health roles. The present study investigated the nature of client rudeness, how mental health workers respond and the coping strategies used. Eighteen participants from a range of mental health roles and experience levels participated in semi-structured interviews based on their experience of client rudeness. Thematic analysis revealed that participants experienced a variety of client behaviours they classified as rude, the majority of which were verbal. Reasons for rudeness included the client's personal history, mood, and mental health, and as such rudeness was conceptualised as simply a part of the job. Client rudeness was found to have both negative and positive outcomes on a range of areas including work and client relationships. Participants identified supervisors and colleagues as key sources of support for coping with rudeness. These findings suggest that rudeness is "part and parcel" of a mental health practitioner's role. Supervisor support and further training are recommended to help practitioners deal with rudeness in practice.

Ovarian cyst haemorrhage as a complication of acute myelomonocytic leukaemia induction therapy.

BACKGROUND: Here we present a case of acute ovarian cyst haemorrhage in a young female during induction therapy for acute myelomonocytic leukaemia (AMML). CASE PRESENTATION: A patient undergoing chemotherapy on the AML19 trial for AMML developed severe abdominal pain and haemodynamic compromise during cycle 2 of fludarabine, cytarabine and idarubicin. The patient was found to have a large ruptured haemorrhagic ovarian cyst on computed tomography. She was managed conservatively due to relative haematological contraindications to surgery and haemodynamic stability following transfer to the high dependency unit. The patient had recently discontinued anticoagulation for pulmonary emboli due to thrombocytopenia. CONCLUSIONS: This highlights the importance of recognising coexistent pathology in patients undergoing high intensity chemotherapy.

'No-one knows where you are': veterinary perceptions regarding safety and risk when alone and on-call.

BACKGROUND: Veterinary work is considered high risk and involves working with a range of hazards, including large animals, high workload and long hours. A key potential hazard is making home visits and providing out-of-hours emergency care, where vets often work alone, without support and must travel long distances. The current study aimed to examine UK veterinary perceptions of safety culture, lone working and on-call tasks to gain a deeper understanding of the risk and hazards involved. METHODS: An online mixed-methods survey was used to gather quantitative data relevant to practice safety culture and qualitative data regarding veterinary perception of lone working and on-call work. A sample of 76 UK veterinarians were recruited. RESULTS: The quantitative results suggest that there may be practice safety culture issues around a lack of communication and discussion pertaining to safety, particularly in terms of maintaining personal safety. Key themes within the qualitative data included the pressure to treat patients, potentially at personal risk, and feeling unsafe when meeting clients alone and in remote locations. CONCLUSION: These findings indicate that personal safety requires more attention and discussion within veterinary practices, and that safety protocols and requirements should be shared with clients.

Thinking Ahead of the Tractor: Driver Safety and Situation Awareness.

Objective: Situation awareness has been identified as a key skill in maintaining safety in high-risk, dynamic industries. However, there is a lack of research evaluating situation awareness requirements and error types in agricultural operators. The aim of this study was to explore situation awareness among farmers in the United Kingdom (UK) when operating heavy agricultural machinery. Method: The study used an online qualitative survey to collect data in three main areas: situation awareness requirements, factors impacting situation awareness, and the safety context for UK farmers. A total of 57 farmers completed the survey, responding to seven open-ended questions. Data were analyzed using directed content analysis. Results: The results indicate the importance of situation awareness for safe and efficient work practice in farming. Situation awareness requirements span the machinery system, including awareness of internal cab systems and the status of implements attached to the external machine. Farmers needed to map and monitor the surrounding conditions in addition to considering personal requirements. Data also indicated the impact of a range of factors, including system-based elements such as blind spots, individual factors such as level of fatigue, and issues related to a lack of knowledge and failure to think ahead on the maintenance of situation awareness. Conclusion: This research highlights the situation awareness requirements for operating agricultural machinery in complex and dynamic environments. By taking a human factors approach, utilizing design and practical interventions, it may be possible to both support and enhance farmer situation awareness and, therefore, reduce errors and adverse incidents.

Investigation of UK Farmer Go/No-Go Decisions in Response to Tractor-Based Risk Scenarios.

OBJECTIVES: Tractors are a source of injury and fatality in agriculture. Despite this farmers continue to engage in risk-taking behaviors, including operating tractors without appropriate equipment. In order to change behaviors and attitudes toward safety, it is important to understand how farmers approach different types of risk relevant to tractor use. The current study used a qualitative approach to investigate farmer perception of four types of tractor-based risk related to self, equipment, lack of safety features, and environment. METHOD: A sample of 148 farmers from the United Kingdom and Ireland was recruited from farming forums to take part in an online scenario-based qualitative study. Participants were presented with 12 tractor-based scenarios, three from each category of risk, and asked to indicate if they would proceed to use the tractor (go) or not (no-go), then report their reasoning. Thematic analysis was used to identify data patterns. RESULTS: Farmers appeared to assess the consequences of risk in broader terms than the risk of injury to themselves; they also evaluated risk in terms of potential costs (e.g., repair bill) and losses (e.g., delay). Analysis indicated that financial risk was considered with more caution than personal risk in many cases. Farmers also considered usability, such as the functionality of tractor seat belts, indicating the importance of ensuring all safety equipment is fit for purpose. CONCLUSION: The management of agricultural risk should consider farmer priorities (such as financial costs) in order to develop effective messaging that focuses on those priorities, with the aim of reducing risk-taking behaviors.

Predictors of Attitudes Toward Non-Technical Skills in Farming.

OBJECTIVES: Farming is a high-risk sector with up to 170,000 worldwide fatalities reported per year; it is therefore vital to identify methods of mitigating the dangers of this industry. Research within high-risk industries, such as aviation, shipping, and agriculture, has identified the importance of non-technical skills (NTS) in maintaining effective, safe performance and reducing error and injury. However, there is a lack of research evaluating factors that may contribute to NTS attitudes and behaviors. As a first step to address this literature gap, the current study evaluated a range of individual and environmental factors as potential predictors of attitudes toward NTS in agriculture. METHOD: A sample of 170 farmers from within the United Kingdom and Ireland were surveyed using an online questionnaire. The questionnaire included measures of personality, stress, attitudes toward safety (safety climate, motivation, and risk), environmental stressors (workload, work-life imbalance), and non-technical skills (team and lone worker). RESULTS: Attitudes toward safety climate, compliance, and motivation showed a significant association with both team-based and lone worker NTS. Conscientiousness correlated positively with the majority of the NTS elements. Multiple regression analysis indicated neuroticism and conscientiousness demonstrated capacity to predict NTS attitudes. Concerns about costs and equipment, attitudes toward safety climate, and safety motivation were also found to be significant predictors of NTS attitudes. CONCLUSION: The results indicate the utility of individual characteristics and environmental factors when predicting farming NTS attitudes. As a result, these elements could be important when evaluating engagement with NTS and developing NTS training initiatives in agriculture.

Clinician and Staff Perspectives on Participating in Practice-based Research (PBR): A Report from the Wisconsin Research and Education Network (WREN).

BACKGROUND: The success of practice-based research (PBR) depends on the willingness of clinicians and staff to incorporate meaningful and useful research protocols into already demanding clinic schedules. The impact of participation on those who implement multiple projects and how to address the issues that arise during this complex process remain incompletely described. This article reports a qualitative evaluation of the experiences of primary care clinicians and clinic staff who participated in multiple PBR projects with the Wisconsin Research and Education Network (WREN). Also included are their suggestions to researchers and clinicians for future collaborations. METHODS: For program evaluation purposes, WREN conducted 4 focus groups at its 2014 annual meeting. The main focus group question was, "How has participation in PBR affected you and your clinic?" A total of 27 project members from 13 clinics participated in 4 groups (physicians, nurses, managers, and other clinical staff). The 2-hour sessions were recorded, transcribed, and analyzed to identify recurring themes. RESULTS: Five major focus group themes emerged: receptivity to research, outcomes as a result of participation, barriers to implementation, facilitators of success, and advice to researchers and colleagues. Focus group members find research valuable and enjoy participating in projects that are relevant to their practice, even though many barriers exist. They indicated that research participation produces clinical changes that they believe result in improved patient care. They offered ways to improve the research process, with particular emphasis on collaborative early planning, project development, and communication before, during, and after a project. CONCLUSIONS: Clinics that participate in WREN projects remain willing to risk potential work constraints because of immediate or impending benefits to their clinical practice and/or patient population. Including a broader array of clinic personnel in the communication processes, especially in the development of relevant research ideas and planning for clinic implementation and ongoing participation in research projects, would address many of the barriers identified in implementing PBR. The themes and supporting quotes identified in this evaluation of WREN projects may inform researchers planning to collaborate with primary care clinics and clinicians and staff considering participating in research endeavors.

The effect of proximity, Tall Man lettering, and time pressure on accurate visual perception of drug names.

OBJECTIVE: The aim of this study is to assess the effect of proximity and time pressure on accurate and effective visual search during medication selection from a computer screen. BACKGROUND: The presence of multiple similar objects in proximity to a target object increases the difficulty of a visual search. Visual similarity between drug names can also lead to selection error. The proximity of several similarly named drugs within a visual field could, therefore, adversely affect visual search. METHOD: In Study 1, 60 nonpharmacy participants selected a target drug name from an array of mock drug packets shown on a computer screen, where one or four similarly named nontargets might be present. Of the participants, 30 completed the task with a time constraint, and the remainder did not. In Study 2, the same experiment was repeated with 28 pharmacy staff. RESULTS: In Study 1, the proximity of multiple similarly named nontargets within the specified visual field reduced selection accuracy and increased reaction times in the nonpharmacists. Time constraint also had an adverse effect. In Study 2, the pharmacy participants showed increased reaction times when multiple nontargets were present, but the time constraint had no effect. There was no effect of Tall Man lettering. CONCLUSION: The presence of multiple similarly named medications in close proximity to a target medication increases the difficulty of the visual search for the target. Tall Man lettering has no impact on this adverse effect. APPLICATION: The widespread use of the alphabetical system in medication storage increases the risk of proximity-based errors in drug selection.

Effects of clinical pathways for common outpatient infections on antibiotic prescribing.

BACKGROUND: Antibiotic overuse in the primary care setting is common. Our objective was to evaluate the effect of a clinical pathway-based intervention on antibiotic use. METHODS: Eight primary care clinics were randomized to receive clinical pathways for upper respiratory infection, acute bronchitis, acute rhinosinusitis, pharyngitis, acute otitis media, urinary tract infection, skin infections, and pneumonia and patient education materials (study group) versus no intervention (control group). Generalized linear mixed effects models were used to assess trends in antibiotic prescriptions for non-pneumonia acute respiratory infections and broad-spectrum antibiotic use for all 8 conditions during a 2-year baseline and 1-year intervention period. RESULTS: In the study group, antibiotic prescriptions for non-pneumonia acute respiratory infections decreased from 42.7% of cases at baseline to 37.9% during the intervention period (11.2% relative reduction) (P<.0001) and from 39.8% to 38.7%, respectively, in the control group (2.8% relative reduction) (P=.25). Overall use of broad-spectrum antibiotics in the study group decreased from 26.4% to 22.6% of cases, respectively (14.4% relative reduction) (P<.0001) and from 20.0% to 19.4%, respectively, in the control group (3.0% relative reduction) (P=.35). There were significant differences in the trends of prescriptions for acute respiratory infections (P<.0001) and broad-spectrum antibiotic use (P=.001) between the study and control groups during the intervention period, with greater declines in the study group. CONCLUSIONS: This intervention was associated with declining antibiotic prescriptions for non-pneumonia acute respiratory infections and use of broad-spectrum antibiotics over the first year. Evaluation of the impact over a longer study period is warranted.

The impact of patient aggression on community pharmacists: a critical incident study.

BACKGROUND: The impact of patient aggression on healthcare staff has been an important research topic over the past decade. However, the majority of that research has focused primarily on hospital staff, with only a minority of studies examining staff in primary care settings such as pharmacies or doctors' surgeries. Moreover, whilst there is an indication that patient aggression can impact the quality of patient care, no research has been conducted to examine how the impact of aggression on staff could affect patient safety. OBJECTIVE: The aim of the current study was to examine the impact of aggression on community pharmacists in Scotland. Three main aspects were examined: the cause of patient aggression, the impact of aggression on pharmacist job performance and pharmacist behaviours in response to aggression. METHOD: A sample of 18 community pharmacists were interviewed using the critical incident technique. In total, 37 incidents involving aggressive patients were transcribed. KEY FINDINGS: Aggression was considered by the majority of participants to be based on a lack of understanding about the role of a pharmacist. More worrying were the reports of near misses and dispensing errors occurring after an aggressive incident had taken place, indicating an adverse effect on patient safety. Pharmacists described using non-technical skills, including leadership, task management, situational awareness and decision-making, in response to aggressive behaviour. CONCLUSIONS: Patient aggression may have a significant impact on patient safety. This could be addressed through training in non-technical skills but further research is required to clarify those skills in pharmacy staff.

Dealing with aggressive methadone patients in community pharmacy: a critical incident study.

BACKGROUND: Community pharmacists are an important link between methadone patients and the health service in the United Kingdom. However, many pharmacists feel ill prepared to deal with methadone patients, with aggressive behavior a particular concern. OBJECTIVE: To assess the perceived impact of methadone patient aggression on pharmacy practice. METHODS: Sixteen registered pharmacists with a minimum of 3 years' work experience were recruited from within 3 Scottish health boards. Critical incident interviews were conducted to assess pharmacist behavior during an interaction with an aggressive methadone patient. RESULTS: Factors considered by pharmacists to have a negative impact on an interaction with an aggressive methadone patient included intoxication of the patient, the presence of a new or an inexperienced pharmacist, and a restricted time frame for dispensing methadone. Positive factors when dealing with aggressive patients were authoritative behavior by the pharmacist, a separate dispensing area for methadone patients, or a solid counter and a positive relationship between pharmacist and patient. CONCLUSION: Aggression from methadone patients is a risk when dispensing methadone. However, action can be taken by the pharmacist to minimize the impact of that aggression on pharmacy practice. The provision of further training and support, particularly to inexperienced pharmacists, could further reduce the negative impact of patient aggression. The present study indicates that such training could be based on nontechnical skills to strengthen current leadership and teamwork behaviors.