Caring for the technology

Two technologies, dosette robots and EPS, illustrate how new routines and discourses emerge when technologies are introduced, and how ‘traditional’ technologies such as paper charts, post-it notes and whiteboards remain critical to the safety of medicines routines.

Staff at Woodland pharmacies regularly described the dosette robot, and their work with it, as contributing to patient safety: ‘Number one reason is patient safety’; ‘Everything is for patient safety’; ‘We got the robot for patient safety’. This well-rehearsed collective narrative appealed to staff and drove the implementation and ongoing use of the robot, although staff were never explicit about what constitutes ‘safety’ nor how the robot contributed to it. We interpret staffs’ statements about safety as resonating with the robot manufacturer’s such as ‘increased accuracy’ compared with the ‘manual preparation method’ enabling ‘the pharmacy to greatly increase safety’ (Document: robot manufacturer’s website). The website also boasts that dosettes are ‘proven to boost adherence rates from 61% to 97%’, and that the robot offers ‘competitive advantage’ through ‘lower production costs’, ‘increase in production speed’, and a ‘significant decrease in labour costs’ (Document: robot manufacturer’s website). The presumed economic benefits were invisible to us; staff did not express any connection between robot and revenue.

Automation of dosette production has not eliminated the need for human care. The robot is never left alone when ‘in production’ (ie, filling dosettes). It has generated new scope for errors and new working routines to address errors. For example, staff must constantly ‘replenish’ the robot’s 400 translucent blue containers; drugs in underfilled containers are beyond the reach of the robot’s suction arm which lifts drugs one-by-one into the programmed dosette cells. This requires technical knowledge about a drug’s stability and sophisticated local knowledge about how fast the lines are—‘slow lines’ demand less frequent attention than ‘fast lines’. The ‘replenishing’ process involves staff ‘deblistering’ tablets or capsules from their packaging by feeding blister packs through a deblistering machine, depositing tablets into shallow plastic trays for labelling by drug name, batch number, description and number of tablets. A coworker pours the tablets into the matched robot container, first selecting the correct container lid—with holes just big enough to enable the suction mechanism to pick out a single tablet for each cell. After filling, staff do manual checks to ensure the dosette contains the right number of items per cell and that pills have not accidently ‘jumped’ from cell to cell as sometimes happens. Certain medicines (‘externals’) are not kept in the robot; they may have limited shelf life after deblistering or be ‘slow lines’. Staff add these manually once the robot has completed a patient’s 4-week set.

The pharmacy has protocols and standard operating procedures but when we enquire of their whereabouts the manager says they are ‘locked in a cupboard in the staff room.’ Probing further we discover that although the robot was installed over 2 years ago they are ‘still working’ on their protocol for dosette production which ‘changes all the time’. The pharmacy manager continues ‘we are so busy and demand is increasing. When we reach the pinnacle we will write something. I usually just ask the staff and they tell me what’s the best way’ (Fieldnote, Willow, 09/01/2018, DS). His quote illustrates the importance of local knowledge, grounded in practice, and how this becomes constructed through informal communication rather than formal protocol.

EPS is central to dispensing routines, but pharmacy staff adopted a range of workarounds to ensure safety that developers of the EPS system may not have envisaged. It was striking that across all pharmacies all prescriptions sent electronically by GPs (via the National Health Service (NHS) ‘spine’) were printed. The working day was punctuated at c.15 minute intervals by staff ‘refreshing’ the EPS screen to view and print new scripts, a routine they considered essential to safe working practice. Only paper had sufficient ‘ecological flexibility’33 to enable swift movement of the prescription around different physical spaces in ways which supported their collaborative working—the same paper prescription passed from person-to-person moving in and out of different working routines. Its materiality was important, serving as a handy checklist for picking medicines off the shelves, checking medicines before ‘bagging up’, and handing the ‘right medicines to the right patients’ (see table 4). Jimi, Woodland’s manager, explained that portable electronic devices would not do the job; they have no access to a secure wireless internet connection. Given his innovation with robot technologies, we interpret this not as resistance to technology per se, rather an expression that the technology is insufficiently flexible for tasks required.33 34

Caring for each other

Caring for each other encompasses a number of practices to ensure safe working as a team. Members of staff were always alert, always listening and ready to take initiative. Staff were able to report errors without fear of negative consequences and we experienced a strong commitment to social cohesion.

Throughout our fieldwork we observed staff diligently pursuing their individual tasks but always poised and available to help a colleague, for example, find a drug, check/sign-off a prescription, move to the dispensary to serve a growing queue of patients, replenish the robot:

Caleb, a technician, arrived at work and mumbled something. Rohima turned to him and said ‘she’s gonna have to call back in half an hour for dosette box issues’. I realised I had no idea which question she was responding to, or where it had come from. There is such a strong sense in this workplace of people being on the alert to subtle cues from colleagues around the site and I realise I am not always ‘tuned in’ and wonder at what seems like an ‘extra sense’ operating between its members to keep things flowing.

(Fieldnote, Willow, 03/01/2018, DS)

We often witnessed staff huddled together to solve a problem, with junior staff encouraged to offer solutions, define processes or suggest procedural changes:

Caleb who has been in ‘production’ appears and strikes up a conversation with Jimi, the pharmacy owner—a discussion about Epilim [sodium valproate] 100 and 200 and stability issues. Caleb suggests that as they use so much of these items in one production run he wonders if they could change its status from ‘external’ to ‘production’. Jimi considers it and answers back ‘if we only filled it once at production, turnover is high.’ Mo, the pharmacist comes over and joins in, suggesting they ask someone. Jimi suggests that Caleb phone Sanofi, the drug company, to ask how long the tablets can remain out of the packets.

(Fieldnote 09/01/2018, Willow pharmacy, DS)

‘Externals’ add considerable extra work to dosette production as they are dealt with manually, but this exchange also highlights how notions of ‘safety’ incorporate understandings of supply and demand, drug-related storage and stability, alongside a welcoming of ideas by senior staff.

We also observed open discussion as challenges arise, with junior members of staff taking the initiative to come up with solutions or refine working routines based on their knowledge and expertise:

Jimi addressed a small group of staff, reflecting on a recent ‘deblistering problem’ when more than one brand of pill ended up in the same container. He told them to ‘be alert’ and made some suggestions for avoiding this in future, acknowledging how difficult it is amidst a ‘sea of gliclazide’.

A few days later, Laila (dispenser responsible for dosettes) spends her lunch break creating a ‘deblistering SOP’. With three steps typed up, she asks Saleem, a pharmacist, what step four should be, adding ‘I can’t believe this—it is like the easiest thing we do’ By the end of the lunch break she has five steps: ‘I will show it to Sameer and Caleb…this is what we do’.

I was struck by the bottom-up, collaborative nature of this exercise. Safety was being worked out on the hoof with everyone included, acknowledgement of its complexity and overall, a sense of commitment and fun. But the formalisation of this into a document seemed at odds with their usual approach of just asking each other.

I learn a few days later that the SOP is now an A4 sheet with 12 bullet points stuck on the wall of which Laila is clearly proud. Nina watched Laila stage a quiz in which she tested Linda’s knowledge, with Naihra joking from the sidelines. It is imperfect in its detail, and appears incomplete.

Nina asked ‘Why did you have to do a SOP…have you devised a new routine?’

Laila ‘No, it was in our heads. Everyone knew, but it wasn’t written down’

Everyone was happy. The equilibrium was restored. The SOP is not so much an instruction of what to do but a reflection of what they now do, a product of teamwork and a consolidation of their collective knowledge.

(Fieldnotes, Willow, 23/01/2018, DS)

This care for one another created an environment which allowed staff to work collaboratively and openly resolve errors. At Willow and Foxglove in particular, staff were encouraged to identify and discuss errors which were regarded as an inevitable aspect of best practice:

if you haven’t spotted any today, are you doing your job properly or are you asleep on the job, just letting things through? Errors keep you on your toes.

(Interview, Pharmacist, Foxglove, 04/02/2019)

In Woodland pharmacies, the category of ‘error’ was noticeably broad and included: discrepancies arising when patient’s medication changed on hospital discharge; robot errors (eg, broken tablets; tablets ‘jumping’ between cells). One consequence of this broad description that incorporated both ‘human’ and ‘technological’ error was that it made talk about errors commonplace, easy, collegiate and—importantly—actionable:

Aiza has grabbed one set of prescriptions belonging to one patient, or so it would seem. Quickly she has spotted an error and tells me ‘this is something you should see. There’s a mix up on names. Two patients with same surname but different addresses—someone has put both prescriptions together.’ Aiza lays out the four prescriptions on the island worktop for me to see that indeed two belong to a ‘D’ and two belong to a ‘S’ but they have the same surname. She shows Raheem the error—‘I almost made up one prescription for two people!’ She does this in a matter of fact, upbeat way. There’s no blame that it was someone else who put the prescriptions together initially. It’s as if she’s taken responsibility for almost making the error herself, had she not checked the names on the top of the prescription so carefully.

(Fieldnote, Foxglove, 16/01/19, NF)

Caring for the patient

Finally, safety emerges out a shared concern to care for patients; automation has not diminished relationships between staff and patients (‘we know our dosette patients’). There are sticky notes and ‘handover sheets’ on the dispensary walls acting as reminders of: ‘dosette patients’ holidays/extra dosettes needed; hospital admissions; medication changes. Staff often made themselves available for dosette queries on their days off.

At Poppy, Marie, a dispenser, explained how she used her initiative to adapt their routine for labelling dosettes to accommodate a patient with too many medicines for one dosette (22 morning; 17 midday; 6 teatime; 18 bedtime). Usually one inlay is placed in each dosette listing the medication it contains, its appearance and dose instructions. Marie explained ‘we actually make two dosette boxes for her, because it doesn’t all fit into [one] box. So she has her pain medications in one box, and in the other box she has the rest.’ When Marie imagined how the dosette might be used beyond the pharmacy, she placed two inlays within each dosette, so each box listed the patient’s full regimen:

So if she ever went into hospital, say if she only grabbed one dosette box and she only took the pain one and they thought, oh, she’s only on painkillers, and she didn’t take the others (…) It will still have the whole list, so then they’ll say to her, ‘Oh, where’s your other medication because it’s on this?’ (…) Yeah, it dawned on me and she has to go back into hospital, and I don’t know what it’s like, if she’s elderly and she’s rushing, she might only pick up one dosette, and then what? The hospital aren’t going to know what she’s on.

(Interview, Dispenser, Poppy, 29/09/2019)

The following extract expresses the reciprocity and strength of staff-patient relationships which endure and surpass the role of automation:

Laila and Saleem are back from their surgery visits to pick up the daily prescriptions. Laila is full of chatter and excitement and has a story to tell. She says that she went into the surgery and it was so full, people everywhere and a really long queue. As she waited, a man, ‘whose dosette we make up’ came up to her and ‘touched her feet, thanked her and said pray for me.’ The three of us talk about what this might mean. I asked Laila ‘is he grateful because you make up his dosettes?’ ‘I don’t know’ she replied, ‘but I was so embarrassed. Everyone was watching me.’ Saleem asked if she was ‘anything to him, like an aunty?’ ‘I’m nothing to him!’ exclaimed Laila, ‘I’m just the girl in the pharmacy.’

(Fieldnote, Willow, 08/01/2018, NF)

Several participants emphasised the importance of getting the right drug to the right patient at the right time as their top safety priority. Staff speculated on imaginary patients and future imagined scenarios by way of performing safety here-and-now, maintaining a rhetorically persuasive account of their high risk environment and embedding these future abstractions into material structures and systems in-house35:

You have to be accurate on what you do. Be prepared, because obviously you have to always double check what you do. It doesn’t matter whichever job you do, and especially if you work in a pharmacy with medication, it’s got to do with someone’s life. As I said, if you give them something wrong, they could end up in hospital, they don’t know where they’re going to end up; they might die, or whatever!

(Interview, Dispenser, Foxglove, 04/02/2019)

Yes, my main worry is a mistake being made, so I have that at the top of my brain all the time. I’m constantly checking that everything is right, that it is the right meds, it’s the right strength, you know the right tablet, every step. (…) Because I’d hate it. (…) like if it was my nan’s meds or something like that and she said, “Oh, a mistake has been made and I’ve taken the wrong meds!” I wouldn’t be very happy, I’d think, well, I think the whole point of the dosette box is to make sure that vulnerable people, like elderly or those who can’t handle their meds, it’s done for them in the correct way. (…) It is a constant worry, it’s a lot of pressure.

(Interview, Dispenser, Lilac, 13/01/2020)

Polypharmacy as a safety issue: whose responsibility?

Our study revealed an important paradox. On the one hand, polypharmacy was visible, pervasive and productive of numerous working routines. On the other, polypharmacy per se was rarely discussed as a safety concern, either between pharmacy staff or between pharmacist and GP. Safety meant close attention to practices ensuring medicines were dispensed as prescribed, and correcting errors pertaining to individual drugs through the clinical check. It did not mean actively challenging polypharmacy per se, even in situations where the volume of prescribing (10+ or 15+ items) might indicate ‘high risk’.

Table 5 illustrates the tension pharmacy staff articulate between dispensing ‘safely’ in the context of inherently risky lists of multiple medicines, from a professional position which distances them from the act of prescribing, the responsibility for which is firmly with the prescriber, usually the GP.