"It’s all about patient safety": co-construction of patient safety in a community pharmacy.

Problem

Medication safety is a key priority in health care. As the number of prescribed medicines increases, the complexity of prescribing, dispensing and consuming medicines increases. The potential risks to patient safety accumulate, with the use of 10+ medicines regarded as high risk polypharmacy. Previous research on medication safety has focused on hospital settings. The few studies in primary care environments - including community pharmacies - tend to adopt an instrumental focus on 'error' and 'error avoidance', although the importance of building more nuanced understandings of the notion of safety is recognised. The role of organizational culture in supporting patient safety remains under-researched. In this presentation we explore how safety is constructed and accomplished in a community pharmacy setting, as part of the wider APOLLO-MM project (www.polypharmacy.org.uk).

Approach

In-depth ethnographic case study within four community pharmacies. In this presentation we focus on data gathered from one case study site, including: observation of organizational routines; shadowing staff; naturalistic interviews; in-depth interviews with pharmacists and key pharmacy team members; and documents. Field notes were typed up on leaving the field. The interview schedule was informed by ethnographic observations; exploring staff accounts of organizational routines and responsibilities, eliciting detailed narratives of experience to investigate the notion of patient safety. Interviews were audio-recorded and transcribed. Documents analysed included standard operating procedures (SOPs), checklists, informal ‘in-house’ documents (memos, reminders), policy documents. Nvivo was used for data storage and management. We present an interim thematic analysis drawing on these diverse datasets.

Findings

Our work is in progress. Ethnographic approaches have been underexploited in healthcare research despite their potential to illuminate complex issues such as the accomplishment of 'safety' and what this means to different actors in the system. We describe the practices and organizational routines which constitute the preparation, production, dispensing of medicines in 'dossette boxes'. In particular we highlight the significance of collaborative work, relational factors, 'hidden work', tacit routines ('know how'), 'on the job' experience and local knowledge in constituting a 'culture of care' and how this orientation towards 'care' embraces patient safety. We draw on practice theory and the sociology of organisational routines to consider how human actors, technologies and other material artefacts interact to accomplish safety in this context.

Consequences

Medication safety is often conceptualized by reference to formal policies, guidelines, SOPs and attention to operational issues (e.g. numbers of staff on duty). Our work draws attention to how safety is achieved in practice through a combination of formal and informal means. Future work will develop these ideas as we conduct ethnography in three further community pharmacies, two general practices (who share medicines management with our case study pharmacies) and longitudinal observation of a cohort of older patients.