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5 May 2011
An ethnographic case study of four GP practices found that repeat prescribing was a complex, technology-supported social practice, requiring collaboration between administrative staff and clinicians, with important implications for patient safety. Although the process appeared mundane, standardised and automated, in practice it involved a high degree of tailoring and complex judgement from administrative staff that required both explicit and tacit knowledge. A gap appeared to exist between formal practice protocols and the real-life activity of repeat prescribing.
Level of evidence
Level 3 (other evidence) according to the SORT criteria.
Action
People involved in repeat prescribing in general practice, and prescribing managers, pshould consider the implications of this study with a view to reviewing repeat prescribing in their organisation. Any review should not focus solely on the formal protocols and standard operating procedures (SOPs), but should also consider the social complexity inherent in repeat prescribing — i.e. the collaboration between doctors, other health professionals, administrative staff, patients and technology. Furthermore, staff training on repeat prescribing should go beyond understanding the protocol and how to use the computer system, but embrace the complexity, particularly the frequent management of uncertainty and the need for practical judgement. An effective two-way communication system between clinicians and administrative staff should be in place, which allows for both individual and organisational learning.
What is the background to this?
The quality and safety of repeat prescribing is an important issue. Repeat prescribing accounts for up to 75% of all prescriptions written, and 80% of drug costs in UK general practice. Repeat prescribing brings benefits of convenience to both doctors and patients. However, repeat prescribing systems are complex and there are safety risks at various points in the process. Some of the key points of the process are outlined in Table 1 below, but more detailed information is available in the NPC document ‘Good practice guide to quality repeat prescribing’ (January 2004).
Table 1. Key points for safe repeat prescribing.
Source: NPC. 10 Top tips for GPs: Strategies for safer prescribing. 2011
Previous research has been mainly quantitative, comprising of retrospective surveys, experimental, or quasi-experimental studies of interventions aimed at improving the efficiency or safety of the process. This qualitative ethnographic study of repeat prescribing in four UK general practices aimed to critically evaluate the assumption that semi-automated, technology-supported protocols improve the effectiveness and safety of repeat prescribing (e.g. by reducing human error). The authors describe how the sociotechnical system (i.e. electronic patient records and the humans who interact with them) operates, and identify both human and technical contributions to quality and safety in repeat prescribing.
What does this study claim?
This study claims that repeat prescribing is 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 administrative staff (e.g. because the drug, dose, or timing differed from what was on the electronic repeat medication list). These exceptions were managed by making situated judgments that enabled administrative staff (sometimes but not always) to bridge the gap between the idealised assumptions about tasks, roles, and interactions (that were built into the electronic patient records 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. However, it was sometimes critical to getting the job done and contributed in subtle ways to safeguarding patients.
So what?
This study highlights the social complexity inherent in the task of repeat prescribing and challenges the assumption that repeat prescribing is a definitive and unambiguous technological process. The study found a substantial model-reality gap — in other words, differences between the official repeat prescribing protocol, what people say they do, and what they actually do around repeat prescribing.
Having formal protocols and SOPs is important, and Table 1 summarises some of the important points for safe prescribing. However, having these processes in place appears to be only one aspect of safe organisational practice. Routines are embedded in three types of organisational structure:
- technological or artefactual (e.g. the electronic patient record, the repeat alert, the post-it note)
- cultural (e.g. social hierarchies, practice ethos, and values as they are understood by staff)
- coordination and control (infrastructures and ways of working that aim to achieve interdependence of different individuals and routines)
The authors suggest that much potential to improve quality and safety in repeat prescribing seems to lie in the cultural, and coordination and control structures. In particular, safety seems to be assured not merely by the protocols, but by an environment of effective, two-way, and blame free communication, preferably with feedback loops that encourage and enable learning by all parties, and that acknowledge what kinds of uncertainty may arise and whose responsibility it is to deal with these. Over half of patient requests for repeat prescriptions were classed as ‘exceptions’ (e.g. the drug was not on the repeat medication list, the dose was different, the drug had been over-requested, medication review was due). Administrative staff were often required to use explicit or tacit knowledge, assume responsibilities and make complex judgments when dealing with these exceptions (e.g. deciding whether to alert a GP to under-use of antipsychotic drugs). GPs (and those involved in the governance arrangements for repeat prescribing systems) should be aware of the uncertainty inherent in many requests for repeat prescriptions.
This study also suggests that there may be no ‘best way’ of managing repeat prescribing. They found that certain components of the routine worked in one practice but not in another. For example, written requests for repeat prescriptions are preferred to telephone requests as they are less vulnerable to error. However, in one practice, telephone and online requests worked efficiently because the organisational structure, physical layout (i.e. separate room away from the distractions of reception), staffing structure and accepted ways of working supported a technology dominant approach.
This study was undertaken in four urban general practices, three of which had over 11,000 patients and were potentially more complex than an average UK practice. While this may not be representative of all practices in the UK, this study is likely to reflect the daily realities of administrative staff discussing ambiguous cases in a crowded room while multi-tasking other activities. People involved in repeat prescribing, and prescribing managers should consider the implications of this study with a view to reviewing repeat prescribing in their organisation.
Design and setting
Ethnographic case study of four urban UK GP practices with diverse organisational characteristics using electronic patient records that supported semi-automation of repeat prescribing. Two practices were recruited through GPs working within the organisations, and two practices were recruited via a PCT-wide invitation. Practices served mixed patient populations ranging from about 6000 to 12,600 patients.
Method
Two researchers undertook 395 hours of ethnographic observation (about four months per practice) of how GP staff (25 doctors, 16 nurses, 4 healthcare assistants, 6 managers and 56 reception or administrative staff) contributed to, and collaborated on, the repeat prescribing routine. Twenty-eight documents and other artefacts relating to repeat prescribing locally and nationally were analysed (e.g. practice repeat prescribing protocols, patient leaflets, NPC documents). The analysis included mapping prescribing routines, describing organisational practices, and drawing these together through narrative synthesis. The authors sought to identify and compare three routines:
- The proxy routine — i.e. local artefacts such as the practice repeat prescribing protocol.
- The ostensive routine — i.e. abstracted understandings held by staff of how a routine is performed (what gets done, by whom, and how?).
- The performative routine — i.e. the range of ways the routine is actually enacted (arrived at by direct observation).
Outcomes and results
Potential threats to patient safety and characteristics of good practice. See ‘What does this study claim?’
Sponsorship UK Medical Research Council.
Further information can be found on NHS Evidence, in the NPC document ‘Good practice guide to quality repeat prescribing’ and in NPC e-learning materials on the repeat medication management process.
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