It was determined that the first investigation would be carried out in the closely controlled environment of the outpatient and inpatient hospital dispensary at Birmingham Children’s Hospital National Health Service Foundation Trust, examining one step in the dispensing process known as accuracy checking. The dispensing process consists of a series of defined reproducible processes some of which comprise of observable multi step tasks. The
dispensing process can be considered, in its simplest form, to begin when a request for a medicine is received in the dispensary. The dispensary itself is a clearly defined geographical area within the pharmacy department. The request, in paper form, will be formally received by being recorded into a log, it then is passed to a pharmacist to be screened. The
pharmacist will ensure that the right drug, in the right dose has been requested for the right patient to be given at the right time(s) of day by the right route. This is known as the “five” patient rights of medicine administration.
In addition, the correct quantity of medicine is ensured and particularly for paediatric patients, the most suitable presentation of medicine supplied, whether a liquid or solid dosage form such as a tablet. Once satisfied the request will be passed onto the next step in the dispensing process, which entails creating a label to be attached to the final container or pack of medicine and selecting the medicine itself. The correct medicine, container, label together with any ancillaries such as a medicine spoon or oral syringe are then assembled as appropriate.
The final step in the process is known as the accuracy checking step, where an appropriately trained operative ensures that the correct medicine has been correctly labelled for the
specified patient according to the request taking into account any amendments the
pharmacist may have requested. The operative carrying out this step of the process could be a pharmacy technician or a pharmacist. This final step, unlike other steps in the dispensing
process is self-contained in that everything required is presented to the operative. Any issues that may have existed have been resolved by the screening pharmacist at the outset of the dispensing process and all the elements, the medicine itself plus labels and ancillaries have been assembled prior to reaching the accuracy checking step.
By selecting a relatively simple task within the dispensing process the focus would remain on error causation brought about through the existence of error forcing conditions within the system rather than a particularly complex task and one arguably atypical of the system as a whole. The approach adopted for this study was a non-participant direct observation of one task in the routine dispensing process. Eighteen pharmacy staff comprising nine pharmacy technicians and nine clinical pharmacists were approached and asked if they would be willing to volunteer to be enrolled in the study, specifically to be observed carrying out the final step in the dispensing process, the final accuracy check. They were advised that the observation was not looking at them and their work so much as the impact, if any that the environment may or may not have on them. Each observation lasted no longer than 30 minutes during which time 2 or 3 medicine requests were accuracy checked. The observer recorded observable actions that each operative made whilst checking the assembled components before them and in addition direct and indirect interruptions were recorded, using a simple notation devised for this investigation, for example if the operative was observed calculating a dose then “CAL” was written. “L” stood for logs item out; “PEW” stood for person enters accuracy checkers workspace and so on.
The key elements for this study were that the task was uniformly consistent and reproducible. The environment comprising of various elements, heat, light, temperature, noise, space was constant. The Hawthorne effect, a process whereby subjects being observed change their behaviour because they are being observed, was mitigated against by virtue of the fact that the observations were explicit and carried out on multiple occasions over a significant period of time, between February and December 2008. Operatives became used to an observer sitting unobtrusively making notes.
Workload acted as a proxy measure for stress, the higher the workload it would be
reasonable to assume that stress levels would also increase. This was recorded in terms of number of individual medicine requests processed through the dispensary by the hour, at the time that each observation took place. An operatives’ emotional state was gauged using a questionnaire that they could choose to complete on each occasion that they undertook this particular task. The development of the questionnaire is described in Chapter 4. They were asked to do this during a four-month (October 2007-January 2008) period prior to the observations commencing. [APPENDIX].
This part of the study was closed by holding two round-table discussions, one with the nine pharmacy technicians and the other with the nine pharmacists; both facilitated by the investigator who had undertaken the observations. Both groups were asked the same
question which was how many steps did they think that it took to accuracy check a medicine. Both groups responded with an answer in the range of 6-8 steps, essentially those listed above as the five rights together with form, quantity and prescriber signature. However, the observed number of steps were 27.9 +/- 16.8 CI 95%(pharmacy technician group average) and 29.6 +/-4.63 CI 95% (pharmacist group average) far exceeded the estimate of either group. The operatives had been clearly distracted during carrying out the accuracy checking process and the most likely cause of distraction were interruptions.