Denham L. Phipps

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.

Evaluation of the Pharmacy Safety Climate Questionnaire in European community pharmacies

OBJECTIVE To evaluate the internal reliability, factor structure and construct validity of the Pharmacy Safety Climate Questionnaire (PSCQ) when applied to a pan-European sample of community pharmacies. DESIGN A cross-sectional survey design was used. SETTING Community pharmacies in Denmark, Germany, the Netherlands, Portugal and Great Britain. PARTICIPANTS A total of 4105 members of the community pharmacy workforce, all drawn from one of the five participating countries. MAIN OUTCOME MEASURES Each participant completed a copy of the Pharmacy Safety Climate Questionnaire in his or her respective language and rated the perceived safety of the pharmacy in which he or she worked. RESULTS Exploratory and confirmatory factor analyses of the data identified four factors that accounted for item responses, with 24 of the original 34 items loading onto them. They were labelled organizational learning, blame culture, working conditions and safety focus. These factors were found to have an acceptable level of reliability (with Cronbachs alpha values ranging from 0.70 to 0.92) and to predict the rating of pharmacy safety. CONCLUSIONS This study provided information on the PSCQs psychometric properties when used in community pharmacies in different European countries. A modified version of the original PSCQ (known as PSCQ-4) is presented, and further work is proposed to demonstrate its application to safety improvements in pharmacies.

Risk-based regulation of healthcare professionals: What are the implications for pharmacists?

One of the key drivers of regulatory reform is minimising the risks associated with healthcare. In order to achieve this, there is a need for the regulatory bodies to have a clear understanding of what comprises risk in the professions under their remit. The current paper examines ways in which risk could be conceptualised, assessed and managed in one of these professions: pharmacy. The authors review studies in healthcare management, safety science and human factors, and consider a range of views about the nature of risk and its relationship to pharmacy practice. This leads to an exploration of the implications for risk-based regulation (for example, revalidation), and of issues to be addressed in further work in thisarea.

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 (χ2(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.

Preventing Acute Kidney Injury: a qualitative study exploring ‘sick day rules’ implementation in primary care

BackgroundIn response to growing demand for urgent care services there is a need to implement more effective strategies in primary care to support patients with complex care needs. Improving primary care management of kidney health through the implementation of ‘sick day rules’ (i.e. temporary cessation of medicines) to prevent Acute Kidney Injury (AKI) has the potential to address a major patient safety issue and reduce unplanned hospital admissions. The aim of this study is to examine processes that may enable or constrain the implementation of ‘sick day rules’ for AKI prevention into routine care delivery in primary care.MethodsForty semi-structured interviews were conducted with patients with stage 3 chronic kidney disease and purposefully sampled, general practitioners, practice nurses and community pharmacists who either had, or had not, implemented a ‘sick day rule’. Normalisation Process Theory was used as a framework for data collection and analysis.ResultsParticipants tended to express initial enthusiasm for sick day rules to prevent AKI, which fitted with the delivery of comprehensive care. However, interest tended to diminish with consideration of factors influencing their implementation. These included engagement within and across services; consistency of clinical message; and resources available for implementation. Participants identified that supporting patients with multiple conditions, particularly with chronic heart failure, made tailoring initiatives complex.ConclusionsImplementation of AKI initiatives into routine practice requires appropriate resourcing as well as training support for both patients and clinicians tailored at a local level to support system redesign.

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.

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.

Integrating Data From the UK National Reporting and Learning System With Work Domain Analysis to Understand Patient Safety Incidents in Community Pharmacy.

Objectives To explore the combined use of a critical incident database and work domain analysis to understand patient safety issues in a health-care setting. Method A retrospective review was conducted of incidents reported to the UK National Reporting and Learning System (NRLS) that involved community pharmacy between April 2005 and August 2010. A work domain analysis of community pharmacy was constructed using observational data from 5 community pharmacies, technical documentation, and a focus group with 6 pharmacists. Reports from the NRLS were mapped onto the model generated by the work domain analysis. Results Approximately 14,709 incident reports meeting the selection criteria were retrieved from the NRLS. Descriptive statistical analysis of these reports found that almost all of the incidents involved medication and that the most frequently occurring error types were dose/strength errors, incorrect medication, and incorrect formulation. The work domain analysis identified 4 overall purposes for community pharmacy: business viability, health promotion and clinical services, provision of medication, and use of medication. These purposes were served by lower-order characteristics of the work system (such as the functions, processes and objects). The tasks most frequently implicated in the incident reports were those involving medication storage, assembly, or patient medication records. Conclusions Combining the insights from different analytical methods improves understanding of patient safety problems. Incident reporting data can be used to identify general patterns, whereas the work domain analysis can generate information about the contextual factors that surround a critical task.

Perceptual control and feedback control in the analysis of complex tasks

Despite its extensive and successful use in the human factors specialists work, there remain challenges for the development of task analysis. One such challenge is posed by the need to capture the features of the dynamic, complex tasks that take place in modern socio-technical systems. In this paper, we discuss the theoretical and practical implications of using perceptual control theory (PCT) as a theoretical grounding for task analysis. In particular, we describe the ability of PCT to combine the notion of perceptual control (which is similar to the assumptions underlying ecological design) with that of feedback control (which is fundamental to some traditional task analysis approaches). We describe some of the current PCT-based task analysis methods before introducing a new method that aims to integrate PCT concepts into hierarchical task analysis. Finally, we demonstrate how this method might be applied to a real-world dynamic control task.

A naturalistic decision-making perspective on anaesthetists' rule-related behaviour

Abstract As a widely recognised feature of work activity, procedural violations have been of considerable interest to human factors specialists, and several models have been proposed to aid in understanding their occurrence. A common feature of these models is that they depict violations as being, to a greater or lesser extent, intentional; therefore, rule-related behaviour could be reconceptualised as an exercise in decision-making. In this paper, we examine anaesthetists’ use of rules from the perspective of naturalistic decision-making. Doing so suggests that their rule-related behaviour is a product of the extent to which following a rule is consistent with other principles that guide their decision-making. Observational and interview data from 23 consultant anaesthetists indicated the presence of three such principles: “doing the right thing”; “doing what works in the circumstances”; and “using one’s skills and expertise”. Hence, rule-related behaviour in this setting is better understood as a form of situated action than as the following or breaking of rules per se. We discuss the implications of this view for understanding why violations occur, and how to address them.