The role of informal dimensions of safety in high-volume organisational routines: An ethnographic study of test results handling in UK general practice

Implementation Science

Volumn 12, Issue 1, 2017, Pages

  Grant, Suzanne ^a   Checkland, Katherine ^b   Bowie, Paul ^c   Guthrie, Bruce ^a  

^a UNIVERSITY OF DUNDEE   (United Kingdom)

^b UNIVERSITY OF MANCHESTER   (United Kingdom)

^c NHS EDUCATION FOR SCOTLAND   (United Kingdom)

Author keywords

Ethnography; General practice; Organisational routines; Primary care; Qualitative; Safety; Test results handling

Indexed keywords

ACHIEVEMENT; ETHNOGRAPHY; GENERAL PRACTICE; HUMAN; HUMAN EXPERIMENT; PARTICIPANT OBSERVATION; PHYSICIAN; PRIMARY MEDICAL CARE; PRODUCTIVITY; SAFETY; SEMI STRUCTURED INTERVIEW; STAFF; TOTAL QUALITY MANAGEMENT; DIAGNOSTIC TEST; PRACTICE GUIDELINE; SPECIMEN HANDLING; STANDARDS; STATISTICS AND NUMERICAL DATA; UNITED KINGDOM;

DIAGNOSTIC TESTS, ROUTINE; GENERAL PRACTICE; HUMANS; PRACTICE GUIDELINES AS TOPIC; SAFETY MANAGEMENT; SPECIMEN HANDLING; UNITED KINGDOM;

EID: 85018296301     PISSN: None     EISSN: 17485908     Source Type: Journal    
DOI: 10.1186/s13012-017-0586-8     Document Type: Article

References (71)

1. Bowie P, Halley L, McKay J. Laboratory test ordering and results management systems: a qualitative study of safety risks identified by administrators in general practice. BMJ Open. 2014;4(2):e004245.
2. Elder NC, Graham D, Brandt E, Dovey S, Phillips R, Ledwith J. The testing process in family medicine: problems, solutions and barriers as seen by physicians and their staff. J Patient Saf. 2006;2(1):25-32.
3. Elder NC, McEwen TR, Flach JM, Gallimore JJ. Management of test results in family medicine offices. Ann Fam Med. 2009;7(4):343-51.
4. Elder NC. Laboratory testing in general practice: a patient safety blind spot. BMJ Qual Saf. 2015;24(11):667-70.
5. Hickner JM, Fernald DH, Harris DM, Poon EG, Elder NC, Mold JW. Issues and initiatives in the testing process in primary care physician offices. Jt Comm J Qual Patient Saf. 2005;31(2):81-9.
6. Poon EG, Gandhi TK, Sequist TD, Murff HJ, Karson AS, Bates DW. "I wish I had seen this test result earlier!": dissatisfaction with test result management systems in primary care. Arch Intern Med. 2004;164(20):2223-8.
7. Roy CL, Poon EG, Karson AS, Ladak-Merchant Z, Johnson RE, Maviglia SM, Gandhi TK. Patient safety concerns arising from test results that return after hospital discharge. Ann Intern Med. 2005;143(2):121-8.
8. Hickner J. Reducing test management errors in primary care office practice. J Patient Saf. 2005;1(1):70-1.
9. Bird S. Missing test results and failure to diagnose. Aust Fam Physician. 2004;33(5):360.
10. Callen J, Georgiou A, Li J, Westbrook JI. The safety implications of missed test results for hospitalised patients: a systematic review. BMJ Qual Saf. 2011;20(2):194-9.
11. Matheny ME, Gandhi TK, Orav EJ, Ladak-Merchant Z, Bates DW, Kuperman GJ, Poon EG. Impact of an automated test results management system on patients' satisfaction about test result communication. Arch Intern Med. 2007;167(20):2233-9.
12. Wahls TL, Cram PM. The frequency of missed test results and associated treatment delays in a highly computerized health system. BMC Fam Pract. 2007;8(1):1.
13. Hollnagel E. Safety-I and safety-II: the past and future of safety management. London: Ashgate; 2014.
14. Rowley E, Waring J. A socio-cultural perspective on patient safety. London: Ashgate; 2011.
15. Lawton R, Taylor N, Clay-Williams R, Braithwaite J. Positive deviance: a different approach to achieving patient safety. BMJ Qual Saf. 2014;23(11):880-3.
16. Braithwaite J, Runciman WB, Merry AF. Towards safer, better healthcare: harnessing the natural properties of complex sociotechnical systems. Qual Saf Health Care. 2009;18(1):37-41.
17. Shojania KG, Thomas EJ. Trends in adverse events over time: why are we not improving? BMJ Qual Saf. 2013;22(4):273-7.
18. Westbrook JI, Braithwaite J, Georgiou A, Ampt A, Creswick N, Coiera E, Iedema R. Multimethod evaluation of information and communication technologies in health in the context of wicked problems and sociotechnical theory. J Am Med Inform Assoc. 2007;14(6):746-55.
19. The Health Foundation. Evidence scan: complex adaptive systems. London: The Health Foundation; 2010.
20. Greenhalgh T, Robert G, Macfarlane F, Bate P, Kyriakidou O. Diffusion of innovations in service organizations: systematic review and recommendations. Milbank Q. 2004;82(4):581-629.
21. Dixon-Woods M, Leslie M, Tarrant C, Bion J. Explaining Matching Michigan: an ethnographic study of a patient safety program. Implement Sci. 2013;8:70.
22. Mesman J. Resources of strength: an exnovation of hidden competences to preserve patient safety. In: Rowley E, Waring J, editors. A sociocultural perspective on patient safety. London: Ashgate Publishing; 2011. p. 71-92.
23. Gabbay RA, Friedberg MW, Miller-Day M, Cronholm PF, Adelman A, Schneider EC. A positive deviance approach to understanding key features to improving diabetes care in the medical home. Ann Fam Med. 2013;11(1):S99-S107.
24. Marra AR, Guastelli LR, de Araújo CMP, dos Santos JLS, Lamblet LCR, Silva M, de Lima G, Cal RG, Paes AT, Cendoroglo NM, Barbosa L, Edmond MB, dos Santos OF. Positive deviance a new strategy for improving hand hygiene compliance. Infect Control Hosp Epidemiol. 2010;31(1):12-20.
25. Bradley EH, Curry LA, Ramanadhan S, Rowe L, Nembhard IM, Krumholz HM. Research in action: using positive deviance to improve quality of health care. Implement Sci. 2009;4(1):1.
26. McNab D, Bowie P, Morrison J, Ross A. Understanding patient safety performance and educational needs using the 'Safety-II' approach for complex systems. Educ Prim Care. 2016;27(6):443-50.
27. Braithwaite J, Wears RL, Hollnagel E. Resilient health care: turning patient safety on its head. International Journal for Quality in Health Care. 2015. doi: 10.1093/intqhc/mzv063.
28. Marsh DR, Schroeder DG, Dearden KA, Sternin J, Sternin M. The power of positive deviance. Br Med J. 2004;329(7475):1177-9.
29. Feldman MS, Pentland BT. Reconceptualizing organizational routines as a source of flexibility and change. Adm Sci Q. 2003;48(1):94-118.
30. Feldman MS. Organizational routines as a source of continuous change. Organ Sci. 2000;11(6):611-29.
31. Pentland BT, Feldman MS. Organizational routines as a unit of analysis. Ind Corp Chang. 2005;14(5):793-815.
32. Grant S, Mesman J, Guthrie B. Spatio-temporal elements of articulation work in the achievement of repeat prescribing safety in UK general practice. Sociol Health Illn. 2015;38(2):306-24.
33. Greenhalgh T. Role of routines in collaborative work in healthcare organisations. BMJ. 2008;337:1269-271.
34. Swinglehurst D, Greenhalgh T. Caring for the patient, caring for the record: an ethnographic study of 'back office' work in upholding quality of care in general practice. BMC Health Serv Res. 2015;15(1):177.
35. Craig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M. Developing and evaluating complex interventions: the new Medical Research Council guidance. Br Med J. 2008;337:979-83.
36. Geertz C. The interpretation of cultures: selected essays. New York: Basic books; 1973.
37. Star SL, Strauss A. Layers of silence, arenas of voice: the ecology of visible and invisible work. Comput Supported Coop Work. 1999;8(1-2):9-30.
38. Nicolini D. Practice theory, work, and organization: an introduction. Oxford: Oxford University Press; 2012.
39. Feldman MS. A performative perspective on stability and change in organizational routines. Ind Corp Chang. 2003;12(4):727-52.
40. Swinglehurst D, Greenhalgh T, Russell J, Myall M. Receptionist input to quality and safety in repeat prescribing in UK general practice: ethnographic case study. BMJ. 2011;343:d6788.
41. Mays N, Pope C. Rigour and qualitative research. Br Med J. 1995;311(6997):109.
42. Braithwaite J, Wears RL, Hollnagel E. Resilient Health Care, Volume 3: Reconciling Work-as-Imagined and Work-as-Done. Boca Raton: CRC Press; 2016.
43. Erasmus V, Daha TJ, Brug H, Richardus JH, Behrendt MD, Vos MC, van Beeck EF. Systematic review of studies on compliance with hand hygiene guidelines in hospital care. Infect Control Hosp Epidemiol. 2010;31(3):283-94.
44. Iedema R, Jorm C, Braithwaite J, Travaglia J, Lum M. A root cause analysis of clinical error: confronting the disjunction between formal rules and situated clinical activity. Soc Sci Med. 2006;63(5):1201-12.
45. Patterson ES. Structuring flexibility: the potential good, bad and ugly in standardisation of handovers. Qual Saf Health Care. 2008;17(1):4-5.
46. Runciman W, Hunt TD, Hannaford NA, Hibbert PD, Westbrook JI, Coeira E, Day R, Hindmarsh DM, McGlynn EA, Braithwaite J. CareTrack: assessing the appropriateness of health care delivery in Australia. Med J Aust. 2012;197(2):100-5.
47. Hollnagel E. The ETTO principle: efficiency-thoroughness trade-off: why things that go right sometimes go wrong. Surrey: Ashgate; 2009.
48. Shojania KG, Dixon-Woods M. 'Bad apples': time to redefine as a type of systems problem? BMJ Qual Saf. 2013;22(7):528-31.
49. Iedema R. New approaches to researching patient safety. Soc Sci Med. 2009;69(12):1701-4.
50. Suchman LA. Plans and situated actions: the problem of human-machine communication. Cambridge: Cambridge University Press; 1987.
51. Patterson EA, Del Mar C. Medical receptionists in general practice: who needs a nurse? Int J Nurs Pract. 2000;6(5):229-36.
52. Pope C. Trouble in store: some thoughts on the management of waiting lists. Sociol Health Illn. 1991;13(2):193-212.
53. Swinglehurst D, Greenhalgh T, Russell J, Myall M. Receptionist input to quality and safety in repeat prescribing in UK general practice: ethnographic case study. Br Med J. 2011;343:d6788.
54. Sellen AJ, Harper RH. The myth of the paperless office. Cambridge: MIT Press; 2003.
55. Berg M. Implementing information systems in health care organizations: myths and challenges. Int J Med Inform. 2001;64(2):143-56.
56. Forsythe DE. Using ethnography in the design of an explanation system. Expert Syst Appl. 1995;8:403-17.
57. Thompson C, McCaughan D, Cullum N, Sheldon T, Raynor P. Barriers to evidence-based practice in primary care nursing-why viewing decision-making as context is helpful. J Adv Nurs. 2005;52(4):432-44.
58. Berg M. Rationalizing medical work. Decision-support techniques and medical practices. Cambridge: MIT Press; 1997.
59. Sheikh A, Cornford T, Barber N, Avery A, Takian A, Lichtner V, Petrakaki D, Crowe S, Marsden K, Robertson A, Morrison Z, Klecun E, Prescott R, Quinn C, Jani Y, Ficociello M, Voutsona K, Paton J, Fernando B, Jacklin A, Cresswell K. Implementation and adoption of nationwide electronic health records in secondary care in England: final qualitative results from prospective national evaluation in "early adopter" hospitals. Br Med J. 2011;343:d6054.
60. Drazen EL, Metzger JB, Ritter JL, Schneider MK. Patient care information systems: successful design and implementation. New York: Springer; 1995.
61. Laudon KC, Laudon JP. Management information systems. New approaches to organization and technology. New York: Macmillan; 1998.
62. Iedema R, Long D, Forsyth R, Lee BB. Visibilising clinical work: video ethnography in the contemporary hospital. Health Sociol Rev. 2006;15(2):156-68.
63. Carroll K, Iedema R, Kerridge R. Reshaping ICU ward round practices using video-reflexive ethnography. Qual Health Res. 2008;18(3):380-90.
64. Collier A, Sorensen R, Iedema R. Patients' and families' perspectives of patient safety at the end of life: a video-reflexive ethnography study. International Journal for Quality in Health Care. 2016;28(1):66-73.
65. Svedung JRI, Rasmussen J. Proactive risk management in a dynamic society. Karlstad: Swedish Rescue Services Agency; 2000.
66. Hawe P, Shiell A, Riley T. Complex interventions: how "out of control" can a randomised controlled trial be? Br Med J. 2004;328(7455):1561-3.
67. May C, Finch T. Implementing, embedding, and integrating practices: an outline of normalisation process theory. Sociology. 2009;43:535-50.
68. Woods DD, Patterson ES, Cook RI. Behind human error: taming complexity to improve patient safety. Handbook Of Human Factors And Ergonomics In Health Care And Patient Safety. 2007. p459-76
69. Department of Health. General practice forward view. London: Stationery Office; 2016.
70. Iedema R. Creating safety by strengthening clinicians' capacity for reflexivity. BMJ Qual Saf. 2011;20(1):i83-i6.
71. Iedema R, Merrick ET, Rajbhandari D, Gardo A, Stirling A, Herkes R. Viewing the taken-for-granted from under a different aspect: a video-based method in pursuit of patient safety. Int J Mult Res Approaches. 2009;3(3):290-301.