Receptionist input to quality and safety in repeat prescribing in UK general practice: ethnographic case study
BMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d6788 (Published 03 November 2011) Cite this as: BMJ 2011;343:d6788
- Deborah Swinglehurst, National Institute for Health Research doctoral fellow1,
- Trisha Greenhalgh, professor of primary health care1,
- Jill Russell, senior lecturer in health policy1,
- Michelle Myall, senior researcher2
- 1Centre for Primary Care and Public Health, Barts and The London School of Medicine and Dentistry, London E1 2AT, UK
- 2WRC Research, London EC1V 0BB, UK
- Correspondence to: D Swinglehurst d.swinglehurst{at}qmul.ac.uk
- Accepted 23 September 2011
Abstract
Objective To describe, explore, and compare organisational routines for repeat prescribing in general practice to identify contributors and barriers to safety and quality.
Design Ethnographic case study.
Setting Four urban UK general practices with diverse organisational characteristics using electronic patient records that supported semi-automation of repeat prescribing.
Participants 395 hours of ethnographic observation of staff (25 doctors, 16 nurses, 4 healthcare assistants, 6 managers, and 56 reception or administrative staff), and 28 documents and other artefacts relating to repeat prescribing locally and nationally.
Main outcome measures Potential threats to patient safety and characteristics of good practice.
Methods Observation of how doctors, receptionists, and other administrative staff contributed to, and collaborated on, the repeat prescribing routine. Analysis included mapping prescribing routines, building a rich description of organisational practices, and drawing these together through narrative synthesis. This was informed by a sociological model of how organisational routines shape and are shaped by information and communications technologies.
Results Repeat prescribing was a complex, technology-supported social practice requiring collaboration between clinical and administrative staff, with important implications for patient safety. More than half of requests for repeat prescriptions were classed as “exceptions” by receptionists (most commonly because the drug, dose, or timing differed from what was on the electronic repeat list). They managed these exceptions by making situated judgments that enabled them (sometimes but not always) to bridge the gap between the idealised assumptions about tasks, roles, and interactions that were built into the electronic patient record and formal protocols, and the actual repeat prescribing routine as it played out in practice. This work was creative and demanded both explicit and tacit knowledge. Clinicians were often unaware of this input and it did not feature in policy documents or previous research. Yet it was sometimes critical to getting the job done and contributed in subtle ways to safeguarding patients.
Conclusion Receptionists and administrative staff make important “hidden” contributions to quality and safety in repeat prescribing in general practice, regarding themselves accountable to patients for these contributions. Studying technology-supported work routines that seem mundane, standardised, and automated, but which in reality require a high degree of local tailoring and judgment from frontline staff, opens up a new agenda for the study of patient safety.
Footnotes
We thank the staff and patients in the general practices for their participation and our project steering group for support, guidance, and advice.
Contributors: TG, DS, and JR contributed to the research proposal, applied for the Medical Research Council grant, and conceptualised the study. TG and DS applied for the ethical approval. DS and MM made applications for National Health Service research governance approval. DS and MM completed the data collection. All authors contributed to the analysis of the data. DS and TG wrote the paper. TG is the guarantor for the paper.
Funding: This work was funded by a research grant from the UK Medical Research Council (Healthcare Electronic Records in Organisations, 07/133) and a National Institute for Health Research doctoral fellowship award (RDA/03/07/076) for DS. The funders were not involved in the selection or analysis of data, or in contributing to the content of the final manuscript.
Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; and no other relationships or activities that could appear to have influenced the submitted work.
Ethical approval: This study was approved by Thames Valley multicentre research ethics committee (06/MRE12/81) in January 2007 and subsequent amendments.
Data sharing: No additional data available.
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