Understanding the informal aspects of medication processes to maintain patient safety in hospitals: a sociotechnical ethnographic study in paediatric units

Adverse drug events (ADEs) are common in hospitals, affecting one in six child in-patients. Medication processes are complex systems. This study aimed to explore the work-as-done of medication safety in three English paediatric units using direct observation and semi-structured interviews. We found that a combination of the physical environment, traditional work systems and team norms were among the systemic barriers to medicines safety. The layout of wards discouraged teamworking and reinforced professional boundaries. Workspaces were inadequate, and interruptions were uncontrollable. A less experienced workforce undertook prescribing and verification while more experienced nurses undertook administration. Guidelines were inadequate, with actors muddling through together. Formal controls against ADEs included checking (of prescriptions and administration) and barcode administration systems, but these did not integrate into workflows. Families played an important part in the safe administration of medication and provision of information about their children but were isolated from other parts of the system.

Medication Safety Gaps in English Pediatric Inpatient Units: An Exploration Using Work Domain Analysis

OBJECTIVES

Medication is a common cause of preventable medical harm in pediatric inpatients. This study aimed to examine the sociotechnical system surrounding pediatric medicines management, to identify potential gaps in this system and how these might contribute to adverse drug events (ADEs).

METHODS

An exploratory prospective qualitative study in pediatric wards in three hospitals in the north of England was conducted between October 2020 and May 2022. Analysis included a documentary analysis of 72 policies and procedures and analysis of field notes from 60 hours of participant observation. The cognitive work analysis prompt framework was used to generate a work domain analysis (WDA) and identify potential contributory factors to ADEs.

RESULTS

The WDA identified 2 functional purposes, 7 value/priority measures, 6 purpose-related functions, 11 object-related processes and 14 objects. Structured means-ends connections supported identification of 3 potential contributory factors-resource limitations, cognitive demands, and adaptation of processes. The lack of resources (equipment, materials, knowledge, and experience) created an environment where distractions and interruptions were unavoidable. Families helped provide practical support in medicines administration but were largely unacknowledged at an organizational level. There was a lack of teamwork with regards to medication with different professionals responsible for different parts of the system. Mandated safety checks on medicines were frequently omitted because of limited resources and perceived redundancy. Interventions to support adherence to safety policies were also often bypassed because they created more work.

CONCLUSIONS

The WDA has provided insights into the complex system of medication safety for children in hospital and has facilitated the identification of potential contributory factors to ADEs. We therefore advocate (in priority order) for processes to involve parents in the care of their children in hospital, development of skill-mix interventions to ensure appropriate expertise is available where it is needed, and modified checking procedures to permit staff to use their skills and judgment effectively and efficiently.

unDerstandIng the cauSes of mediCation errOrs and adVerse drug evEnts for patients with mental illness in community caRe (DISCOVER): a qualitative study

Background

It is estimated that 237 million medication errors occur in England each year with a significant number occurring in the community. Our understanding of the causes of preventable medication errors and adverse drug events (ADE) affecting patients with mental illness is limited in this setting. Better understanding of the factors that contribute to errors can support the development of theory-driven improvement interventions.

Methods

Remote qualitative semi-structured interviews with 26 community-based healthcare professionals in England and Wales were undertaken between June-November 2022. Recruitment was undertaken using purposive sampling via professional networks. Interviews were guided by the critical incident technique and analysed using the framework method. Any data that involved speculation was not included in the analysis. Independent analysis was carried out by the research team to extract themes guided by the London Protocol.

Results

A total of 43 medication errors and 12 preventable ADEs were discussed, with two ADEs having an unknown error origin. Prescribing errors were discussed most commonly (n = 24), followed by monitoring errors (n = 8). Six contributory factor themes were identified: the individual (staff); the work environment; the teams/interfaces; the organisation and management; the patient; and the task and technology. The individual (staff) factors were involved in just over 80% of all errors discussed. Participants reported a lack of knowledge regarding psychotropic medication and mental illnesses which accompanied diffusion of responsibility. There were difficulties with team communication, particularly across care interfaces, such as ambiguity/brevity of information being communicated and uncertainty concerning roles which created confusion amongst staff. Unique patient social/behavioural contributory factors were identified such as presenting with challenging behaviour and complex lifestyles, which caused difficulties attending appointments as well as affecting overall clinical management.

Conclusion

These findings highlight that the causes of errors are multifactorial with some unique to this patient group. Key areas to target for improvement include the education/training of healthcare professionals regarding neuropharmacology/mental illnesses and enhancing communication across care interfaces. Future research should explore patient perspectives regarding this topic to help develop a holistic picture. These findings can be used to guide future intervention research to ameliorate medication safety challenges for this patient group.

Clinical checking in practice: qualitative perspectives from community pharmacists

OBJECTIVES

Community pharmacists (CPs) are the last healthcare professional to check the clinical appropriateness of prescribed medicines before being dispensed to patients. This process is known as 'clinical checking' and is intended to ensure the prescribed medications are safe and effective. This study aims to explore how CPs carry out clinical checking in practice, and the main factors affecting their clinical decisions.

METHODS

The study was qualitative in nature, and data were collected by means of semi-structured interviews. The interview questions aimed to explore how CPs carry out clinical checking in practice. A purposive sampling strategy was employed to recruit a sample representative of CPs in England. Interview transcripts were subjected to thematic template analysis.

KEY FINDINGS

Twelve CPs of various professional backgrounds participated in the interviews. The analysis yielded three overarching themes, namely: pharmacists' perception of the clinical checking process; clinical checking as a naturalistic decision-making process and barriers to effective clinical checking. Interviewees described being faced with a trade-off between examining each prescription thoroughly and maintaining the throughput of prescriptions, due to the highly pressurised environment they work within. A number of factors inform this trade-off: (1) assuming the safety of repeat medicines; (2) lacking access to sufficient clinical information and (3) working under challenging circumstances (such as a lack of resources).

CONCLUSIONS

Clinical checking is a complex, variable and experience-driven process which is heavily influenced by the surrounding environment and information accessibility. Further research should investigate the cognitive process involved in clinical checking and explore the practicalities and potential benefits of the recommendations identified in this study.

Understanding medication safety involving patient transfer from intensive care to hospital ward: a qualitative sociotechnical factor study

OBJECTIVE

To understand the sociotechnical factors affecting medication safety when intensive care patients are transferred to a hospital ward. Consideration of these medication safety factors would provide a theoretical basis, on which future interventions can be developed and evaluated to improve patient care.

DESIGN

Qualitative study using semistructured interviews of intensive care and hospital ward-based healthcare professionals. Transcripts were anonymised prior to thematic analysis using the London Protocol and Systems Engineering in Patient Safety V.3.0 model frameworks.

SETTING

Four north of England National Health Service hospitals. All hospitals used electronic prescribing in intensive care and hospital ward settings.

PARTICIPANTS

Intensive care and hospital ward healthcare professionals (intensive care medical staff, advanced practitioners, pharmacists and outreach team members; ward-based medical staff and clinical pharmacists).

RESULTS

Twenty-two healthcare professionals were interviewed. We identified 13 factors within five broad themes, describing the interactions that most strongly influenced the performance of the intensive care to hospital ward system interface. The themes were: Complexity of process performance and interactions; Time pressures and considerations; Communication processes and challenges; Technology and systems and Beliefs about consequences for the patient and organisation.

CONCLUSIONS

The complexity of the interactions on the system performance and time dependency was clear. We make several recommendations for policy change and further research based on improving: availability of hospital-wide integrated and functional electronic prescribing systems, patient flow systems, sufficient multiprofessional critical care staffing, knowledge and skills of staff, team performance, communication and collaboration and patient and family engagement.

Predicting dispensing errors in community pharmacies: An application of the Systematic Human Error Reduction and Prediction Approach (SHERPA)

Introduction

The objective of this study was to use a prospective error analysis method to examine the process of dispensing medication in community pharmacy settings and identify remedial solutions to avoid potential errors, categorising them as strong, intermediate, or weak based on an established patient safety action hierarchy tool.

Method

Focus group discussions and non-participant observations were undertaken to develop a Hierarchical Task Analysis (HTA), and subsequent focus group discussions applied the Systematic Human Error Reduction and Prediction Approach (SHERPA) focusing on the task of dispensing medication in community pharmacies. Remedial measures identified through the SHERPA analysis were then categorised as strong, intermediate, or weak based on the Veteran Affairs National Centre for Patient Safety action hierarchy. Non-participant observations were conducted at 3 pharmacies, totalling 12 hours, based in England. Additionally, 7 community pharmacists, with experience ranging from 8 to 38 years, participated in a total of 4 focus groups, each lasting between 57 to 85 minutes, with one focus group discussing the HTA and three applying SHERPA. A HTA was produced consisting of 10 sub-tasks, with further levels of sub-tasks within each of them.

Results

Overall, 88 potential errors were identified, with a total of 35 remedial solutions proposed to avoid these errors in practice. Sixteen (46%) of these remedial measures were categorised as weak, 14 (40%) as intermediate and 5 (14%) as strong according to the Veteran Affairs National Centre for Patient Safety action hierarchy. Sub-tasks with the most potential errors were identified, which included ‘producing medication labels’ and ‘final checking of medicines’. The most common type of error determined from the SHERPA analysis related to omitting a check during the dispensing process which accounted for 19 potential errors.

Discussion

This work applies both HTA and SHERPA for the first time to the task of dispensing medication in community pharmacies, detailing the complexity of the task and highlighting potential errors and remedial measures specific to this task. Future research should examine the effectiveness of the proposed remedial solutions to improve patient safety.

Trading off accuracy and explainability in AI decision-making: findings from 2 citizens' juries

Objective

To investigate how the general public trades off explainability versus accuracy of artificial intelligence (AI) systems and whether this differs between healthcare and non-healthcare scenarios.

Materials and Methods

Citizens’ juries are a form of deliberative democracy eliciting informed judgment from a representative sample of the general public around policy questions. We organized two 5-day citizens’ juries in the UK with 18 jurors each. Jurors considered 3 AI systems with different levels of accuracy and explainability in 2 healthcare and 2 non-healthcare scenarios. Per scenario, jurors voted for their preferred system; votes were analyzed descriptively. Qualitative data on considerations behind their preferences included transcribed audio-recordings of plenary sessions, observational field notes, outputs from small group work and free-text comments accompanying jurors’ votes; qualitative data were analyzed thematically by scenario, per and across AI systems.

Results

In healthcare scenarios, jurors favored accuracy over explainability, whereas in non-healthcare contexts they either valued explainability equally to, or more than, accuracy. Jurors’ considerations in favor of accuracy regarded the impact of decisions on individuals and society, and the potential to increase efficiency of services. Reasons for emphasizing explainability included increased opportunities for individuals and society to learn and improve future prospects and enhanced ability for humans to identify and resolve system biases.

Conclusion

Citizens may value explainability of AI systems in healthcare less than in non-healthcare domains and less than often assumed by professionals, especially when weighed against system accuracy. The public should therefore be actively consulted when developing policy on AI explainability.

Mind the gap: Examining work-as-imagined and work-as-done when dispensing medication in the community pharmacy setting

Reducing errors within a healthcare setting remains high on the patient safety research agenda. More consistent performance has been sought by increased development of standardised operating procedures, but they are not always adhered to in practice. Previous studies have identified that a difference exists between the way a task is imagined to be completed, based on standardised protocols and procedures, and how the task is actually completed in reality. This study explores one area of healthcare, community pharmacy, and more specifically the task of dispensing medicines from prescriptions, to identify the gap between how dispensing is imagined to be completed through standardised operating procedures, and how it is actually completed in practice, by using Hierarchical Task Analysis as a framework. Document analysis of standardised operating procedures in 3 community pharmacies was used to produce 3 task analyses, which were compared with 3 task analyses produced from data collected through non-participant observations of the same 3 community pharmacies. Deviations between the two forms of task analyses were presented to community pharmacists in focus group discussions and it was found staff may deviate from standardised protocols because of various reasons, including: efficiency; availability of resources; thoroughness; and delegating safeguards. Potential implications for the work system include the benefit of greater collaboration between procedure writers and frontline workers, and the introduction of more flexible procedures, that allow the risks of any adaptions to be clearly realised. Further work must establish whether pharmacists recognise the safety implications of these gaps between work as imagined, and work as done, and initiatives should be established to ensure patient safety is not compromised due to these differences.

The role of non-technical skills in community pharmacy practice: an exploratory review of the literature

BACKGROUND

Non-technical skills (NTS) are the cognitive and social skills that complement technical skills in safe and efficient practice, and include leadership, teamwork, task management, decision-making and situation awareness. Other areas within healthcare have heavily invested in producing taxonomies to aid training and assessment of NTS within their disciplines, and have found them to be essential for improving patient safety. In pharmacy, no validated taxonomy has been produced, nor has the existing literature been appraised to aid the future development of a validated taxonomy.

OBJECTIVE(S)

To examine the literature on NTS within a community pharmacy setting and establish the research conducted thus far on each NTS and how they are applied by community pharmacists.

METHODS

A literature search of six electronic databases (EMBASE, PsychINFO, Medline, SCOPUS, CINAHL Plus and HMIC) using the generic list of NTS identified in previous studies. Only empirical studies were included. Examples of behaviours or skills were extracted and categorised within each NTS.

KEY FINDINGS

Seventeen studies were identified that contained one or more examples of NTS specific to community pharmacy practice. Altogether, 16 elements were extracted. Four elements were identified within leadership and task management. A further three were identified within situation awareness and decision-making, and a final two within teamwork and communication.

CONCLUSION

A framework consisting of the skills and how they're applied has been presented which describe the NTS required by community pharmacists from the published literature. This framework can provide a foundation for further investigation into NTS use within pharmacy practice.

Evaluation of a pharmacist-led actionable audit and feedback intervention for improving medication safety in UK primary care: An interrupted time series analysis

BACKGROUND

We evaluated the impact of the pharmacist-led Safety Medication dASHboard (SMASH) intervention on medication safety in primary care.

METHODS AND FINDINGS

SMASH comprised (1) training of clinical pharmacists to deliver the intervention; (2) a web-based dashboard providing actionable, patient-level feedback; and (3) pharmacists reviewing individual at-risk patients, and initiating remedial actions or advising general practitioners on doing so. It was implemented in 43 general practices covering a population of 235,595 people in Salford (Greater Manchester), UK. All practices started receiving the intervention between 18 April 2016 and 26 September 2017. We used an interrupted time series analysis of rates (prevalence) of potentially hazardous prescribing and inadequate blood-test monitoring, comparing observed rates post-intervention to extrapolations from a 24-month pre-intervention trend. The number of people registered to participating practices and having 1 or more risk factors for being exposed to hazardous prescribing or inadequate blood-test monitoring at the start of the intervention was 47,413 (males: 23,073 [48.7%]; mean age: 60 years [standard deviation: 21]). At baseline, 95% of practices had rates of potentially hazardous prescribing (composite of 10 indicators) between 0.88% and 6.19%. The prevalence of potentially hazardous prescribing reduced by 27.9% (95% CI 20.3% to 36.8%, p < 0.001) at 24 weeks and by 40.7% (95% CI 29.1% to 54.2%, p < 0.001) at 12 months after introduction of SMASH. The rate of inadequate blood-test monitoring (composite of 2 indicators) reduced by 22.0% (95% CI 0.2% to 50.7%, p = 0.046) at 24 weeks; the change at 12 months (23.5%) was no longer significant (95% CI -4.5% to 61.6%, p = 0.127). After 12 months, 95% of practices had rates of potentially hazardous prescribing between 0.74% and 3.02%. Study limitations include the fact that practices were not randomised, and therefore unmeasured confounding may have influenced our findings.

CONCLUSIONS

The SMASH intervention was associated with reduced rates of potentially hazardous prescribing and inadequate blood-test monitoring in general practices. This reduction was sustained over 12 months after the start of the intervention for prescribing but not for monitoring of medication. There was a marked reduction in the variation in rates of hazardous prescribing between practices.

Understanding the utilisation of a novel interactive electronic medication safety dashboard in general practice: a mixed methods study

BACKGROUND

Improving medication safety is a major concern in primary care settings worldwide. The Salford Medication safety dASHboard (SMASH) intervention provided general practices in Salford (Greater Manchester, UK) with feedback on their safe prescribing and monitoring of medications through an online dashboard, and input from practice-based trained clinical pharmacists. In this study we explored how staff working in general practices used the SMASH dashboard to improve medication safety, through interactions with the dashboard to identify potential medication safety hazards and their workflow to resolve identified hazards.

METHODS

We used a mixed-methods study design involving quantitative data from dashboard user interaction logs from 43 general practices during the first year of receiving the SMASH intervention, and qualitative data from semi-structured interviews with 22 pharmacists and physicians from 18 practices in Salford.

RESULTS

Practices interacted with the dashboard a median of 12.0 (interquartile range, 5.0-15.2) times per month during the first quarter of use to identify and resolve potential medication safety hazards, typically starting with the most prevalent hazards or those they perceived to be most serious. Having observed a potential hazard, pharmacists and practice staff worked together to resolve that in a sequence of steps (1) verifying the dashboard information, (2) reviewing the patient's clinical records, and (3) deciding potential changes to the patient's medicines. Over time, dashboard use transitioned towards regular but less frequent (median of 5.5 [3.5-7.9] times per month) checks to identify and resolve new cases. The frequency of dashboard use was higher in practices with a larger number of at-risk patients. In 24 (56%) practices only pharmacists used the dashboard; in 12 (28%) use by other practice staff increased as pharmacist use declined after the initial intervention period; and in 7 (16%) there was mixed use by both pharmacists and practice staff over time.

CONCLUSIONS

An online medication safety dashboard enabled pharmacists to identify patients at risk of potentially hazardous prescribing. They subsequently worked with GPs to resolve risks on a case-by-case basis, but there were marked variations in processes between some practices. Workload diminished over time as it shifted towards resolving new cases of hazardous prescribing.

Mapping the prevalence and nature of drug related problems among hospitalised children in the United Kingdom: a systematic review

BACKGROUND

Problems arising from medicines usage are recognised as a key patient safety issue. Children are a particular concern, given that they are more likely than adults to experience medication-related harm. While previous reviews have provided an estimate of prevalence in this population, these predate recent developments in the delivery of paediatric care. Hence, there is a need for an updated, focussed and critical review of the prevalence and nature of drug-related problems in hospitalised children in the UK, in order to support the development and targeting of interventions to improve medication safety.

METHODS

Nine electronic databases (Medline, Embase, CINAHL, PsychInfo, IPA, Scopus, HMIC, BNI, The Cochrane library and clinical trial databases) were searched from January 1999 to April 2019. Studies were included if they were based in the UK, reported on the frequency of adverse drug reactions (ADRs), adverse drug events (ADEs) or medication errors (MEs) affecting hospitalised children. Quality appraisal of the studies was also conducted.

RESULTS

In all, 26 studies were included. There were no studies which specifically reported prevalence of adverse drug events. Two adverse drug reaction studies reported a median prevalence of 25.6% of patients (IQR 21.8-29.9); 79.2% of reactions warranted withdrawal of medication. Sixteen studies reported on prescribing errors (median prevalence 6.5%; IQR 4.7-13.3); of which, the median rate of dose prescribing errors was 11.1% (IQR 2.9-13). Ten studies reported on administration errors with a median prevalence of 16.3% (IQR 6.4-23). Administration technique errors represented 53% (IQR 52.7-67.4) of these errors. Errors detected during medicines reconciliation at hospital admission affected 43% of patients, 23% (Range 20.1-46) of prescribed medication; 70.3% (Range 50-78) were classified as potentially harmful. Medication errors detected during reconciliation on discharge from hospital affected 33% of patients and 19.7% of medicines, with 22% considered potentially harmful. No studies examined the prevalence of monitoring or dispensing errors.

CONCLUSIONS

Children are commonly affected by drug-related problems throughout their hospital journey. Given the high prevalence and risk of patient harm,, there is a need for a deeper theoretical understanding of paediatric medication systems to enable more effective interventions to be developed to improve patient safety.

Mapping the territory of renal care: a formative analysis of the cognitive work involved in managing acute kidney injury

The design and evaluation of healthcare work systems requires an understanding of the cognitive work involved in healthcare tasks. Previous studies suggest that a formative approach would be particularly useful to examine healthcare activities for this purpose. In the present study, methods from cognitive work analysis and cognitive task analysis are combined in a formative examination of managing acute kidney injury, an activity that occurs across primary and secondary healthcare settings. The analyses are informed by interviews with healthcare practitioners and a review of practice guidelines. The findings highlight ways in which the task setting influenced practitioners' activity, and ways in which practitioners approached the activity (for example, how they used data to make decisions). The approach taken provided a rich understanding of the cognitive work involved, as well as generating suggestions for the design of work systems to support the clinical task. Practitioner summary: Healthcare tasks often require decision-making in complex and dynamic circumstances, potentially involving collaboration across different practitioner roles and locations. We demonstrate the use of a formative analysis to understand the cognitive work in managing a clinical syndrome across primary and secondary care settings, and consider the implications for work design.

Exploring the human factors of prescribing errors in paediatric intensive care units

OBJECTIVE

To explore the factors contributing to prescribing error in paediatric intensive care units (PICUs) using a human factors approach based on Reason's theory of error causation to support planning of interventions to mitigate slips and lapses, rules-based mistakes and knowledge-based mistakes.

METHODS

A hierarchical task analysis (HTA) of prescribing was conducted using documentary analysis. Eleven semistructured interviews with prescribers were conducted using vignettes and were analysed using template analysis. Contributory factors were identified through the interviews and were related to tasks in the HTA by an expert panel involving a PICU clinician, nurse and pharmacist.

RESULTS

Prescribing in PICU is composed of 30 subtasks. Our findings indicate that cognitive burden was the main contributory factor of prescribing error. This manifested in two ways: physical, associated with fatigue, distraction and interruption, and poor information transfer; and psychological, related to inexperience, changing workload and insufficient decision support information. Physical burden was associated with errors of omission or selection; psychological burden was linked to errors related to a lack of knowledge and/or awareness. Social control through nursing staff was the only identified control step. This control was dysfunctional at times as nurses were part of an informal mechanism to support decision making, was ineffective.

CONCLUSIONS

Cognitive burden on prescribers is the principal latent factor contributing to prescribing error. This research suggests that interventions relating to skill mix, and communication and presentation of information may be effective at mitigating rule and knowledge-based mistakes. Mitigating fatigue and standardising procedures may minimise slips and lapses.

Developing a learning health system: Insights from a qualitative process evaluation of a pharmacist-led electronic audit and feedback intervention to improve medication safety in primary care

INTRODUCTION

Developments in information technology offer opportunities to enhance medication safety in primary care. We evaluated the implementation and adoption of a complex pharmacist-led intervention involving the use of an electronic audit and feedback surveillance dashboard to identify patients potentially at risk of hazardous prescribing or monitoring of medicines in general practices. The intervention aimed to create a rapid learning health system for medication safety in primary care. This study aimed to explore how the intervention was implemented, adopted and embedded into practice using a qualitative process evaluation.

METHODS

Twenty two participants were purposively recruited from eighteen out of forty-three general practices receiving the intervention as well as clinical commissioning group staff across Salford UK, which reflected the range of contexts in which the intervention was implemented. Interviews explored how pharmacists and GP staff implemented the intervention and how this affected care practice. Data analysis was thematic with emerging themes developed into coding frameworks based on Normalisation Process Theory (NPT).

RESULTS

Engagement with the dashboard involved a process of sense-making in which pharmacists considered it added value to their work. The intervention helped to build respect, improve trust and develop relationships between pharmacists and GPs. Collaboration and communication between pharmacists and clinicians was primarily initiated by pharmacists and was important for establishing the intervention. The intervention operated as a rapid learning health system as it allowed for the evidence in the dashboard to be translated into changes in work practices and into transformations in care.

CONCLUSIONS

Our study highlighted the importance of the combined use of information technology and the role of pharmacists working in general practice settings. Medicine optimisation activities in primary care may be enhanced by the implementation of a pharmacist-led electronic audit and feedback system. This intervention established a rapid learning health system that swiftly translated data from electronic health records into changes in practice to improve patient care. Using NPT provided valuable insights into the ways in which developing relationships, collaborations and communication between health professionals could lead to the implementation, adoption and sustainability of the intervention.

Organizational conditions for engagement in quality and safety improvement: a longitudinal qualitative study of community pharmacies

Background

While efforts have been made to bring about quality and safety improvement in healthcare, it remains by no means certain that an improvement project will succeed. This suggests a need to better understand the process and conditions of improvement. The current study addresses this question by examining English community pharmacies attempting to undertake improvement activities.

Method

The study used a longitudinal qualitative design, involving a sample of ten community pharmacies. Each pharmacy took part in a series of improvement workshops, involving use of the Manchester Patient Safety Framework (MaPSaF), over a twelve-month period. Qualitative data were collected from the workshops, from follow-up focus groups and from field notes. Template analysis was used to identify themes in the data.

Results

The progress made by pharmacies in improving their practice can be described in terms of a behavioural change framework, consisting of contemplation (resolving to make changes if they are required), planning (deciding how to carry out change) and execution (carrying out and reflecting on change). Organizational conditions supporting change were identified; these included the prioritisation of improvement, a commitment to change, a trusting and collaborative relationship between staff and managers, and knowledge about quality and safety issues to work on.

Conclusions

Our study suggests a process by which healthcare work units might undergo improvement. In addition to recognising and providing support for this process, it is important to establish an environment that fosters improvement, and for work units to ensure that they are prepared for undergoing improvement activities.

Understanding procedural violations using Safety-I and Safety-II: The case of community pharmacies

OBJECTIVE

Procedural violations are known to occur in a range of work settings, and are an important topic of interest with regard to safety management. A Safety-I perspective sees violations as undesirable digressions from standardised procedures, while a Safety-II perspective sees violations as adaptations to a complex work system. This study aimed to apply both perspectives to the examination of violations in community pharmacies.

DESIGN

Twenty-four participants (13 pharmacists and 11 pharmacy support staff) were purposively sampled to participate in semi-structured interviews using the critical incident technique. Participants described violations they made during the course of their work. Interviews were digitally recorded, transcribed verbatim and analysed using template analysis.

SETTING

Community pharmacies located in England and Wales.

RESULTS

31 procedural violations were described during the interviews revealing multiple reasons for violations in this setting. Our findings suggest that from a Safety-II perspective, staff violated to adapt to situations and to manage safety. However, participants also violated procedures in order to maintain productivity which was found to increase risk in some, but not all situations. Procedural violations often relied on the context in which staff were working, resulting in the violation being deemed rational to the individual making the violation, yet the behaviour may be difficult to justify from an outside perspective.

CONCLUSIONS

Combining Safety-I and Safety-II perspectives provided a detailed understanding of the underlying reasons for procedural violations. Our findings identify aspects of practice that could benefit from targeted interventions to help support staff in providing safe patient care.

Mindful organizing in patients' contributions to primary care medication safety

Background

There is a need to ensure that the risks associated with medication usage in primary health care are controlled. To maintain an understanding of the risks, health‐care organizations may engage in a process known as “mindful organizing.” While this is typically conceived of as involving organizational members, it may in the health‐care context also include patients. Our study aimed to examine ways in which patients might contribute to mindful organizing with respect to primary care medication safety.

Method

Qualitative focus groups and interviews were carried out with 126 members of the public in North West England and the East Midlands. Participants were taking medicines for a long‐term health condition, were taking several medicines, had previously encountered problems with their medication or were caring for another person in any of these categories. Participants described their experiences of dealing with medication‐related concerns. The transcripts were analysed using a thematic method.

Results

We identified 4 themes to explain patient behaviour associated with mindful organizing: knowledge about clinical or system issues; artefacts that facilitate control of medication risks; communication with health‐care professionals; and the relationship between patients and the health‐care system (in particular, mutual trust).

Conclusions

Mindful organizing is potentially useful for framing patient involvement in safety, although there are some conceptual and practical issues to be addressed before it can be fully exploited in this setting. We have identified factors that influence (and are strengthened by) patients’ engagement in mindful organizing, and as such would be a useful focus of efforts to support patient involvement.

What is involved in medicines management across care boundaries? A qualitative study of healthcare practitioners' experiences in the case of acute kidney injury

OBJECTIVES

To examine the role of individual and collective cognitive work in managing medicines for acute kidney injury (AKI), this being an example of a clinical scenario that crosses the boundaries of care organisations and specialties.

DESIGN

Qualitative design, informed by a realist perspective and using semistructured interviews as the data source. The data were analysed using template analysis.

SETTING

Primary, secondary and intermediate care in England.

PARTICIPANTS

12 General practitioners, 10 community pharmacists, 7 hospital doctors and 7 hospital pharmacists, all with experience of involvement in preventing or treating AKI.

RESULTS

We identified three main themes concerning participants' experiences of managing medicines in AKI. In the first theme, challenges arising from the clinical context, AKI is identified as a technically complex condition to identify and treat, often requiring judgements to be made about renal functioning against the context of the patient's general well-being. In the second theme, challenges arising from the organisational context, the crossing of professional and organisational boundaries is seen to introduce problems for the coordination of clinical activities, for example by disrupting information flows. In the third theme, meeting the challenges, participants identify ways in which they overcome the challenges they face in order to ensure effective medicines management, for example by adapting their work practices and tools.

CONCLUSIONS

These themes indicate the critical role of cognitive work on the part of healthcare practitioners, as individuals and as teams, in ensuring effective medicines management during AKI. Our findings suggest that the capabilities underlying this work, for example decision-making, communication and team coordination, should be the focus of training and work design interventions to improve medicines management for AKI or for other conditions.

When procedures meet practice in community pharmacies: qualitative insights from pharmacists and pharmacy support staff

OBJECTIVES

Our aim was to explore how members of community pharmacy staff perceive and experience the role of procedures within the workplace in community pharmacies.

SETTING

Community pharmacies in England and Wales.

PARTICIPANTS

24 community pharmacy staff including pharmacists and pharmacy support staff were interviewed regarding their view of procedures in community pharmacy. Transcripts were analysed using thematic analysis.

RESULTS

3 main themes were identified. According to the 'dissemination and creation of standard operating procedures' theme, community pharmacy staff were required to follow a large amount of procedures as part of their work. At times, complying with all procedures was not possible. According to the 'complying with procedures' theme, there are several factors that influenced compliance with procedures, including work demands, the high workload and the social norm within the pharmacy. Lack of staff, pressure to hit targets and poor communication also affected how able staff felt to follow procedures. The third theme 'procedural compliance versus using professional judgement' highlighted tensions between the standardisation of practice and the professional autonomy of pharmacists. Pharmacists feared being unsupported by their employer for working outside of procedures, even when acting for patient benefit. Some support staff believed that strictly following procedures would keep patients and themselves safe. Dispensers described following the guidance of the pharmacist which sometimes meant working outside of procedures, but occasionally felt unable to voice concerns about not working to rule.

CONCLUSIONS

Organisational resilience in community pharmacy was apparent and findings from this study should help to inform policymakers and practitioners regarding factors likely to influence the implementation of procedures in community pharmacy settings. Future research should focus on exploring community pharmacy employees' intentions and attitudes towards rule-breaking behaviour and the impact this may have on patient safety.

Job characteristics, well-being and risky behaviour amongst pharmacists

Healthcare practitioners' fitness to practise has often been linked to their personal and demographic characteristics. It is possible that situational factors, such as the work environment and physical or psychological well-being, also have an influence on an individual's fitness to practise. However, it is unclear how these factors might be linked to behaviours that risk compromising fitness to practise. The aim of this study was to examine the association between job characteristics, well-being and behaviour reflecting risky practice amongst a sample of registered pharmacists in a region of the United Kingdom. Data were obtained from a cross-sectional self-report survey of 517 pharmacists. These data were subjected to principal component analysis and path analysis, with job characteristics (demand, autonomy and feedback) and well-being (distress and perceived competence) as the predictors and behaviour as the outcome variable. Two aspects of behaviour were found: Overloading (taking on more work than one can comfortably manage) and risk taking (working at or beyond boundaries of safe practice). Separate path models including either job characteristics or well-being as independent variables provided a good fit to the data-set. Of the job characteristics, demand had the strongest association with behaviour, while the association between well-being and risky behaviour differed according to the aspect of behaviour being assessed. The findings suggest that, in general terms, situational factors should be considered alongside personal factors when assessing, judging or remediating fitness to practise. They also suggest the presence of different facets to the relationship between job characteristics, well-being and risky behaviour amongst pharmacists.

Examining the attitudes of hospital pharmacists to reporting medication safety incidents using the theory of planned behaviour

OBJECTIVE

To assess the effect of factors within hospital pharmacists' practice on the likelihood of their reporting a medication safety incident.

DESIGN

Theory of planned behaviour (TPB) survey.

SETTING

Twenty-one general and teaching hospitals in the North West of England.

PARTICIPANTS

Two hundred and seventy hospital pharmacists (response rate = 45%).

INTERVENTION

Hospital pharmacists were invited to complete a TPB survey, based on a prescribing error scenario that had resulted in serious patient harm. Multiple regression was used to determine the relative influence of different TPB variables, and participant demographics, on the pharmacists' self-reported intention to report the medication safety incident.

MAIN OUTCOME MEASURES

The TPB variables predicting intention to report: attitude towards behaviour, subjective norm, perceived behavioural control and descriptive norm.

RESULTS

Overall, the hospital pharmacists held strong intentions to report the error, with senior pharmacists being more likely to report. Perceived behavioural control (ease or difficulty of reporting), Descriptive Norms (belief that other pharmacists would report) and Attitudes towards Behaviour (expected benefits of reporting) showed good correlation with, and were statistically significant predictors of, intention to report the error [R = 0.568, R(2) = 0.323, adjusted R(2) = 0.293, P < 0.001].

CONCLUSIONS

This study suggests that efforts to improve medication safety incident reporting by hospital pharmacists should focus on their behavioural and control beliefs about the reporting process. This should include instilling greater confidence about the benefits of reporting and not harming professional relationships with doctors, greater clarity about what/not to report and a simpler reporting system.

Exploring safety systems for dispensing in community pharmacies: focusing on how staff relate to organizational components

Background

Identifying risk is an important facet of a safety practice in an organization. To identify risk, all components within a system of operation should be considered. In clinical safety practice, a team of people, technologies, procedures and protocols, management structure and environment have been identified as key components in a system of operation.

Objectives

To explore risks in relation to prescription dispensing in community pharmacies by taking into account relationships between key components that relate to the dispensing process.

Methods

Fifteen community pharmacies in England with varied characteristics were identified, and data were collected using non-participant observations, shadowing and interviews. Approximately 360 hours of observations and 38 interviews were conducted by the team. Observation field notes from each pharmacy were written into case studies. Overall, 52,500 words from 15 case studies and interview transcripts were analyzed using thematic and line-by-line analyses. Validation techniques included multiple data collectors co-authoring each case study for consensus, review of case studies by members of the wider team including academic and practicing community pharmacists, and patient safety experts and two presentations (internally and externally) to review and discuss findings.

Results

Risks identified were related to relationships between people and other key components in dispensing. This included how different levels of staff communicated internally and externally, followed procedures, interacted with technical systems, worked with management, and engaged with the environment. In a dispensing journey, the following categories were identified which show how risks are inextricably linked through relationships between human components and other key components: 1) dispensing with divided attention; 2) dispensing under pressure; 3) dispensing in a restricted space or environment; and, 4) managing external influences.

Conclusions

To identify and evaluate risks effectively, an approach that includes understanding relationships between key components in dispensing is required. Since teams of people in community pharmacies are a key dispensing component, and therefore part of the operational process, it is important to note how they relate to other components in the environment within which they operate. Pharmacies can take the opportunity to reflect on the organization of their systems and review in particular how they can improve on the four key categories identified.

Career breaks and changes of sector: challenges for the revalidation of pharmacists

BACKGROUND

Taking a career break or moving between sectors of practice (for example, between patient-facing and non-patient-facing roles) often has been assumed to pose a risk for pharmacists' fitness to practice. However, it is not clear what the nature of that risk is, or what its implications are for professional revalidation.

OBJECTIVES

To explore: (i) the experiences of pharmacists who either return to practice following a career break or move from one sector of practice to another; and (ii) the experiences of those who support or observe pharmacists undergoing one of these changes.

METHODS

Eighteen registered pharmacists in Northern Ireland, all of whom had either undergone a change in practice themselves or had supported another pharmacist through a change in practice, took part in a telephone-based interview. During the interviews, each participant was invited to reflect upon his or her experiences of the change and suggest ways in which such processes should be handled in the future. The interview transcripts were thematically analysed using template analysis.

RESULTS

A number of themes captured the issues discussed relating to changes in practice. Firstly, there is a variety of circumstances surrounding a change in practice; secondly, there are various ways in which a pharmacist can prepare for a change in practice; thirdly, a number of factors were thought to facilitate or hinder the process. Finally, training and development needs were identified for pharmacists undergoing a change.

CONCLUSIONS

A revalidation scheme for pharmacists should make provision for registrants who have taken a career break or changed sector. Such registrants would benefit from resources to support them through the change in practice; these resources could come from peers, employers, or the regulator.

Understanding the attitudes of hospital pharmacists to reporting medication incidents: a qualitative study

BACKGROUND

The attitudes of doctors, nurses, and midwives to reporting errors in health care have been extensively studied, but there is very limited literature considering pharmacists' attitudes to medication error reporting schemes, in particular in hospitals.

OBJECTIVES

To explore and understand the attitudes of hospital pharmacists to reporting medication incidents.

METHODS

Focus groups were conducted with a total of 17 hospital pharmacists from 4 purposively sampled hospitals in the North West of England. The recordings of the focus groups were transcribed verbatim and subject to thematic analysis using a framework analysis approach.

RESULTS

Pharmacists agreed that the high prevalence of medication errors, especially prescribing errors of omission, has led to an acceptance of not using hospital reporting systems. There were different personal thresholds for reporting medication errors but pharmacists agreed that the severity of any patient harm was the primary reporting driver. Hospital pharmacists had specific anxieties about the effects of reporting on interprofessional working relationships with doctors and nurses, but felt more confident to report if they had previously witnessed positive feedback and system change following an error. Existing reporting forms were considered too cumbersome and time consuming to complete, as pharmacists felt the need to find and record every possible detail.

CONCLUSIONS

Hospital pharmacists understood the importance of reporting medication incidents, but because of the high number of errors they encounter do not report them as often as may be expected. The decision to report was a complex process that depended on the severity of patient harm, anxieties about harming interprofessional relationships, prior experience of the outcomes from reporting, and the perceived effort required to use reporting forms.

Psychosocial influences on safety climate: evidence from community pharmacies

OBJECTIVE

To examine the relationship between psychosocial job characteristics and safety climate.

DESIGN

Cross-sectional survey.

SETTING

Community pharmacies in Great Britain. Participants A random sample of community pharmacists registered in Great Britain (n = 860). Survey instruments Effort-reward imbalance (ERI) indicator and Job Content Questionnaire (JCQ). Main outcome measures Pharmacy Safety Climate Questionnaire (PSCQ).

RESULTS

The profile of scores from the ERI indicated a relatively high risk of adverse psychological effects. The profile of scores from the JCQ indicated both high demand on pharmacists and a high level of psychological and social resources to meet these demands. Path analysis confirmed a model in which the ERI and JCQ measures, as well as the type of pharmacy and pharmacist role, predicted responses to the PSCQ (χ(2)(36) = 111.38, p < 0.001; Tucker-Lewis index = 0.96; comparative fit index = 0.98; root mean square error of approximation=0.05). Two general factors (effort vs reward and control vs demand) accounted for the effect of job characteristics on safety climate ratings; each had differential effects on the PSCQ scales.

CONCLUSIONS

The safety climate in community pharmacies is influenced by perceptions of job characteristics, such as the level of job demands and the resources available to meet these demands. Hence, any efforts to improve safety should take into consideration the effect of the psychosocial work environment on safety climate. In addition, there is a need to address the presence of work-related stressors, which have the potential to cause direct or indirect harm to staff and service users. The findings of the current study provide a basis for future research to improve the safety climate and well-being, both in the pharmacy profession and in other healthcare settings.

Extending hierarchical task analysis to identify cognitive demands and information design requirements

While hierarchical task analysis (HTA) is well established as a general task analysis method, there appears a need to make more explicit both the cognitive elements of a task and design requirements that arise from an analysis. One way of achieving this is to make use of extensions to the standard HTA. The aim of the current study is to evaluate the use of two such extensions--the sub-goal template (SGT) and the skills-rules-knowledge (SRK) framework--to analyse the cognitive activity that takes place during the planning and delivery of anaesthesia. In quantitative terms, the two methods were found to have relatively poor inter-rater reliability; however, qualitative evidence suggests that the two methods were nevertheless of value in generating insights about anaesthetists' information handling and cognitive performance. Implications for the use of an extended HTA to analyse work systems are discussed.

Pharmacists subjected to disciplinary action: characteristics and risk factors

OBJECTIVE To establish whether there are any characteristics of pharmacists that predict their likelihood of being subjected to disciplinary action. METHODS  The setting was the Royal Pharmaceutical Society of Great Britain's Disciplinary Committee. One hundred and seventeen pharmacists, all of whom had been referred to the Disciplinary Committee, were matched with a quota sample of 580 pharmacists who had not been subjected to disciplinary action but that matched the disciplined pharmacists on a set of demographic factors (gender, country of residence, year of registration). Frequency analysis and regression analysis were used to compare the two groups of pharmacists in terms of sector of work, ethnicity, age and country of training. Descriptive statistics were also obtained from the disciplined pharmacists to further explore characteristics of disciplinary cases and those pharmacists who undergo them. KEY FINDINGS  While a number of characteristics appeared to increase the likelihood of a pharmacist being referred to the disciplinary committee, only one of these - working in a community pharmacy - was statistically significant. Professional misconduct accounted for a greater proportion of referrals than did clinical malpractice, and approximately one-fifth of pharmacists who went before the Disciplinary Committee had previously been disciplined by the Society. CONCLUSIONS  This study provides initial evidence of pharmacist characteristics that are associated with an increased risk of being disciplined, based upon the data currently available. It is recommended that follow-up work is carried out using a more extensive dataset in order to confirm the statistical trends identified here.

Determinants of intention to deviate from clinical practice guidelines

The volitional nature of procedural violations in work systems creates a challenge for human factors research and practice. In order to understand how violations are caused and what can be done to mitigate them, there is a need to determine the influence of workers' beliefs about rules and guidelines. This study demonstrates the use of a social psychological approach to investigate the beliefs of anaesthetists about clinical practice guidelines. A survey was completed by 629 consultant anaesthetists, who rated their beliefs about deviation from three guidelines (performing pre-operative visits; checking anaesthetic equipment; handling intravenous fluid bags). Regression analysis indicated that the belief ratings predicted self-rated intention to deviate from the guidelines. Implications for understanding anaesthetists' adherence to guidelines are discussed. STATEMENT OF RELEVANCE: This study builds upon previous work by the authors, presenting a more detailed insight into potential causes of procedural violations in healthcare. The study also demonstrates the use of a social psychological method to the investigation of violations. Hence, it is of interest to researchers and practitioners interested in human reliability, especially in healthcare.

Medication safety in community pharmacy: a qualitative study of the sociotechnical context

Background

While much research has been conducted on medication safety, few of these studies have addressed primary care, despite the high volume of prescribing and dispensing of medicines that occurs in this setting. Those studies that have examined primary care dispensing emphasised the need to understand the role of sociotechnical factors (that is, the interactions between people, tasks, equipment and organisational structures) in promoting or preventing medication incidents. The aim of this study was to identify sociotechnical factors that community pharmacy staff encounter in practice, and suggest how these factors might impact on medication safety.

Methods

Sixty-seven practitioners, working in the North West of England, took part in ten focus groups on risk management in community pharmacy. The data obtained from these groups was subjected to a qualitative analysis to identify recurrent themes pertaining to sociotechnical aspects of medication safety.

Results

The findings indicated several characteristics of participants' work settings that were potentially related to medication safety. These were broadly classified as relationships involving the pharmacist, demands on the pharmacist and management and governance of pharmacists.

Conclusion

It is recommended that the issues raised in this study be considered in future work examining medication safety in primary care.

Identifying violation-provoking conditions in a healthcare setting

Procedural violations (intentional deviations from established protocols) are prone to occur in many occupational settings, with a potentially detrimental effect on quality or safety. They are thought to result from organisational practices and the social characteristics of rule-related behaviour. This study makes use of qualitative methods to investigate the nature and causes of violations in anaesthetic practice. Twenty-three consultant anaesthetists took part in the study, which involved naturalistic observations and semi-structured interviews. Several factors influencing anaesthetic violations were identified. These include the nature of the rule, the anaesthetist (both as an individual and as a professional group) and the situation. Implications for the understanding and management of human reliability issues within an organisation are discussed. This study provides an insight into procedural violations, which pose a threat to organisational safety but are distinct from human errors. The study also demonstrates the value of qualitative methods in ergonomics research. It is of relevance to researchers and practitioners interested in human reliability and error, especially in healthcare.