Receptionist input to quality and safety in repeat prescribing in UK general practice: ethnographic case study

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.

Fig 1 Study protocol

Fig 2 Prescribing alert slip from Beech practice. This artefact, a photocopied slip of paper, had been developed by practice staff to manage requests for repeat prescriptions that were in some way problematic

Fig 3 Ostensive routine for repeat prescribing in Beech practice. Area between horizontal broken lines represents the core part of the routine

Fig 4 Repeat prescription request screen in electronic patient record in EMIS Access, accessible online by patient