Using sociotechnical theory to understand medication safety work in primary care and prescribers' use of clinical decision support: a qualitative study.

Mark Jeffries; Nde-Eshimuni Salema; Libby Laing; Azwa Shamsuddin; Aziz Sheikh; Tony Avery; Antony Chuter; Justin Waring; Richard Neil Keers

Study

Using sociotechnical theory to understand medication safety work in primary care and prescribers' use of clinical decision support: a qualitative study.

May 24, 2023

Jeffries M, Salema N-E, Laing L, et al. BMJ Open. 2023;13(4):e068798.

View more articles from the same authors.

Clinical decision support (CDS) systems were developed to support safe medication ordering, alerting prescribers to potential unsafe interactions such as drug-drug, drug-allergy, and dosing errors. This study uses a sociotechnical framework to understand the relationship between primary care prescribers’ safety work and CDS. Prescribers described the usefulness of CDS but also noted alert fatigue.

PubMed citation

Free full text

Related Resources From the Same Author(s)

Understanding factors that could influence patient acceptability of the use of the PINCER intervention in primary care: a qualitative exploration using the Theoretical Framework of Acceptability.

November 9, 2022

The frequency and nature of prescribing problems by general practitioners in training (REVISiT).

June 15, 2022

Electronic prescribing systems in hospitals to improve medication safety: a multi-methods research programme.

December 21, 2022

Estimating the impact on patient safety of enabling the digital transfer of patients' prescription information in the English NHS.

April 17, 2024

Developing a learning health system: insights from a qualitative process evaluation of a pharmacist-led electronic audit and feedback intervention to improve medication safety in primary care.

November 14, 2018

Bayesian cohort and cross-sectional analyses of the PINCER trial: a pharmacist-led intervention to reduce medication errors in primary care.

June 27, 2012

Professional, structural and organisational interventions in primary care for reducing medication errors.

October 18, 2017

Evaluating the safety of mental health-related prescribing in UK primary care: a cross-sectional study using the Clinical Practice Research Datalink (CPRD).

September 15, 2021

Improving general practice computer systems for patient safety: qualitative study of key stakeholders.

February 28, 2007

Adaptive regulation or governmentality: patient safety and the changing regulation of medicine.

April 11, 2007

Doctors' thinking about 'the system' as a threat to patient safety.

January 3, 2007

Information technology-based approaches to reducing repeat drug exposure in patients with known drug allergies.

June 18, 2008

Incidence, nature and causes of avoidable significant harm in primary care in England: retrospective case note review.

December 16, 2020

A multi-method exploratory evaluation of a service designed to improve medication safety for patients with monitored dosage systems following hospital discharge.

October 25, 2023

"Water cooler" learning: knowledge sharing at the clinical "backstage" and its contribution to patient safety.

September 1, 2010

A patient safety toolkit for family practices.

April 25, 2018

Policy and practice in the use of root cause analysis to investigate clinical adverse events: mind the gap.

July 20, 2011

Patient safety culture in care homes for older people: a scoping review.

December 13, 2017

The limits of knowledge management for UK public services modernization: the case of patient safety and service quality.

July 2, 2008

Rules, safety and the narrativisation of identity: a hospital operating theatre case study.

March 15, 2006

'Balancing risk, that is my life': The politics of risk in a hospital operating theatre department.

January 18, 2006

Characterising the nature of primary care patient safety incident reports in the England and Wales National Reporting and Learning System: a mixed-methods agenda-setting study for general practice.

October 12, 2016

Sources of unsafe primary care for older adults: a mixed-methods analysis of patient safety incident reports.

June 7, 2017

Scaffolding our systems? Patients and families 'reaching in' as a source of healthcare resilience.

January 16, 2019

An exploratory study of knowledge brokering in hospital settings: facilitating knowledge sharing and learning for patient safety?

January 29, 2014

Improving responses to safety incidents: we need to talk about justice.

February 23, 2022

Workarounds to hospital electronic prescribing systems: a qualitative study in English hospitals.

May 18, 2016

Safety risks associated with the lack of integration and interfacing of hospital health information technologies: a qualitative study of hospital electronic prescribing systems in England.

April 27, 2016

Understanding medication safety involving patient transfer from intensive care to hospital ward: a qualitative sociotechnical factor study.

June 7, 2023

Interventions in primary care to reduce medication related adverse events and hospital admissions: systematic review and meta-analysis.

February 15, 2006

Exploring the roots of unintended safety threats associated with the introduction of hospital ePrescribing systems and candidate avoidance and/or mitigation strategies: a qualitative study.

February 22, 2017

Understanding the medication safety challenges for patients with mental illness in primary care: a scoping review.

June 28, 2023

Drivers of unprofessional behaviour between staff in acute care hospitals: a realist review.

December 20, 2023

Healthcare professional and patient codesign and validation of a mechanism for service users to feedback patient safety experiences following a care transfer: a qualitative study.

October 5, 2016

The problem with root cause analysis.

July 13, 2016

What does safety in mental healthcare transitions mean for service users and other stakeholder groups: an open-ended questionnaire study.

March 3, 2021

Clinical decision support systems could be modified to reduce 'alert fatigue' while still minimizing the risk of litigation.

January 4, 2012

Prevalence, nature, severity and preventability of adverse drug events in mental health settings: findings from the MedicAtion relateD harm in mEntal health hospitals (MADE) study.

August 11, 2021

Patient safety incidents involving sick children in primary care in England and Wales: a mixed methods analysis.

February 1, 2017

Identifying 'avoidable harm' in family practice: a RAND/UCLA Appropriateness Method consensus study.

November 13, 2019

Patient safety features of clinical computer systems: questionnaire survey of GP views.

June 29, 2005

PReSaFe: A model of barriers and facilitators to patients providing feedback on experiences of safety.

December 7, 2016

Patients' conceptualizations of responsibility for healthcare: a typology for understanding differing attributions in the context of patient safety.

June 5, 2019

Implementing a survey for patients to provide safety experience feedback following a care transition: a feasibility study

October 9, 2019

unDerstandIng the cauSes of mediCation errOrs and adVerse drug evEnts for patients with mental illness in community caRe (DISCOVER): a qualitative study.

February 28, 2024

Prevalence and nature of medication errors and medication-related harm following discharge from hospital to community settings: a systematic review.

July 22, 2020

Taking a detour: positive and negative effects of supervisors' interruptions during admission case review discussions.

October 3, 2012

Sustained user engagement in health information technology: the long road from implementation to system optimization of computerized physician order entry and clinical decision support systems for prescribing in hospitals in England.

November 1, 2017

Influences on the adoption of patient safety innovation in primary care: a qualitative exploration of staff perspectives.

August 22, 2018

Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis.

July 31, 2019

Preventable medication harm across health care settings: a systematic review and meta-analysis.

February 17, 2021

Safety incidents in the primary care office setting.

May 20, 2015

Scaling-up a pharmacist-led information technology intervention (PINCER) to reduce hazardous prescribing in general practices: multiple interrupted time series study.

January 11, 2023

An assessment of basic patient safety skills in residents entering the first year of clinical training.

June 6, 2018

Harms from discharge to primary care: mixed methods analysis of incident reports.

December 16, 2015

Frequency and nature of medication errors and adverse drug events in mental health hospitals: a systematic review.

September 13, 2017

Computerized provider order entry implementation: no association with increased mortality rates in an intensive care unit.

July 19, 2006

Patient safety incidents and adverse events in ambulatory dental care: a systematic scoping review.

October 5, 2016

Analysis of the nature and contributory factors of medication safety incidents following hospital discharge using National Reporting and Learning System (NRLS) data from England and Wales: a multi-method study.

June 7, 2023

Prevalence, nature and predictors of omitted medication doses in mental health hospitals: a multi-centre study.

March 11, 2020

Content analysis of patient safety incident reports for older adult patient transfers, handovers, and discharges: do they serve organizations, staff, or patients?

January 8, 2020

A call to bridge across silos during care transitions.

May 30, 2018

Understanding the causes of intravenous medication administration errors in hospitals: a qualitative critical incident study.

April 1, 2015

Causes of medication administration errors in hospitals: a systematic review of quantitative and qualitative evidence.

September 18, 2013

Prevalence and nature of medication administration errors in health care settings: a systematic review of direct observational evidence.

March 27, 2013

Identifying potential prescribing safety indicators related to mental health disorders and medications: a systematic review.

August 14, 2019

Prevalence and nature of medication errors and preventable adverse drug events in paediatric and neonatal intensive care settings: a systematic review.

December 11, 2019

Effects of interorganisational information technology networks on patient safety: a realist synthesis.

December 9, 2020

Evaluation of medium-term consequences of implementing commercial computerized physician order entry and clinical decision support prescribing systems in two 'early adopter' hospitals.

February 19, 2014

The Orthopaedic Error Index: development and application of a novel national indicator for assessing the relative safety of hospital care using a cross-sectional approach.

December 18, 2013

A pharmacist-led information technology intervention for medication errors (PINCER): a multicentre, cluster randomised, controlled trial and cost-effectiveness analysis.

March 7, 2012

What can safety cases offer for patient safety? A multisite case study.

October 11, 2023

Hassle in the dispensary: pilot study of a proactive risk monitoring tool for organisational learning based on narratives and staff perceptions.

June 8, 2011

Medication safety in mental health hospitals: a mixed-methods analysis of incidents reported to the National Reporting and Learning System.

August 4, 2021

Impact of a commercial order entry system on prescribing errors amenable to computerised decision support in the hospital setting: a prospective pre–post study.

April 18, 2018

Patient safety incidents describing patient falls in critical care in North West England between 2009 and 2017.

April 21, 2021

Identifying, understanding and overcoming barriers to medication error reporting in hospitals: a focus group study.

April 11, 2012

Nature of blame in patient safety incident reports: mixed methods analysis of a national database.

September 27, 2017

Evaluating the implementation and impact of a pharmacy technician-supported medicines administration service designed to reduce omitted doses in hospitals: a qualitative study.

June 12, 2019

Impact of interventions designed to reduce medication administration errors in hospitals: a systematic review.

June 25, 2014

Supporting nursing, midwifery and allied health professional students to raise concerns with the quality of care: a review of the research literature.

August 23, 2017

System hazards in managing laboratory test requests and results in primary care: medical protection database analysis and conceptual model.

January 20, 2016

The impact of eHealth on the quality and safety of health care: a systematic overview.

February 2, 2011

Implementation, evaluation, and recommendations for extension of AHRQ Common Formats to capture patient- and carepartner-generated safety data.

July 11, 2018

A mixed-methods analysis of patient safety incidents involving opioid substitution treatment with methadone or buprenorphine in community-based care in England and Wales.

November 11, 2020

Surgeon agreement at the time of handover, a prospective cohort study.

April 27, 2016

What causes medication administration errors in a mental health hospital? A qualitative study with nursing staff.

January 23, 2019

Fostering patient safety competencies using multiple-patient simulation experiences.

December 9, 2009

Changing cardiac arrest and hospital mortality rates through a medical emergency team takes time and constant review.

February 3, 2010

Evaluation of detected medication errors within the operating room at an academic medical center.

June 21, 2023

Classification of patient-safety incidents in primary care.

September 26, 2018

Mixed-methods evaluation of real-time safety reporting by hospitalized patients and their care partners: the MySafeCare application.

June 13, 2018

How do physicians conduct medication reviews?

December 16, 2009

Proactive patient safety: focusing on what goes right in the perioperative environment.

May 24, 2023

Clinicians' perspectives on proactive patient safety behaviors in the perioperative environment.

April 26, 2023

Assessing legislative potential to institute error transparency: a state comparison of malpractice claims rates.

June 2, 2010

Computerized physician order entry: promise, perils, and experience.

February 12, 2014

Seniors managing multiple medications: using mixed methods to view the home care safety lens.

March 2, 2016

Ten principles for more conservative, care-full diagnosis.

October 10, 2018

Development of a medication safety and quality survey for small rural hospitals.

December 6, 2017

Related Resources

The effect of computerised decision support alerts tailored to intensive care on the administration of high-risk drug combinations, and their monitoring: a cluster randomised stepped-wedge trial.

February 14, 2024

The impact of transition to a digital hospital on medication errors (TIME study).

August 16, 2023

Patient Safety Innovations

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

May 31, 2023

Human factors and safety analysis methods used in the design and redesign of electronic medication management systems: a systematic review.

May 17, 2023

Interview

In Conversation with... Susan McGrath, PhD and George Blike, MD about Surveillance Monitoring

April 26, 2023

Perspective

Surveillance Monitoring to Improve Patient Safety in Acute Hospital Care Units

April 26, 2023

Indication documentation and indication-based prescribing within electronic prescribing systems: a systematic review and narrative synthesis.

April 5, 2023

Perspectives on Safety

Annual Perspective

Technology as a Tool for Improving Patient Safety

March 29, 2023

WebM&M Cases

Duplicate Therapies in Retail Pharmacy

March 15, 2023

WebM&M Cases

Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case for Appropriate Interruptive Drug-Disease Alerts.

February 1, 2023

Electronic prescribing systems in hospitals to improve medication safety: a multi-methods research programme.

December 21, 2022

Health system redesign of cardiac monitoring oversight to optimize alarm management, safety, and staff engagement.

December 14, 2022

Concerns regarding tablet splitting: a systematic review.

December 7, 2022

Journal Article

Study

Clinician collaboration to improve clinical decision support: the Clickbusters initiative.

November 16, 2022

Journal Article

Study

Patient Safety Innovations

Predicting dispensing errors in community pharmacies: an application of the Systematic Human Error Reduction and Prediction Approach (SHERPA).

November 16, 2022

Understanding factors that could influence patient acceptability of the use of the PINCER intervention in primary care: a qualitative exploration using the Theoretical Framework of Acceptability.

November 9, 2022

Improving diagnostic decision support through deliberate reflection: a proposal.

November 9, 2022

Medication adverse events in the ambulatory setting: a mixed-methods analysis.

October 26, 2022

The impact of electronic communication of medication discontinuation (CancelRx) on medication safety: a pilot study.

October 5, 2022

Allergic adverse drug events after alert overrides in hospitalized patients.

September 21, 2022

Overriding drug-drug interaction alerts in clinical decision support systems: a scoping review.

September 7, 2022

Changes to primary care delivery during the COVID-19 pandemic and perceived impact on medication safety: a survey study.

June 29, 2022

The potential for leveraging machine learning to filter medication alerts.

May 4, 2022

Overall performance of a drug-drug interaction clinical decision support system: quantitative evaluation and end-user survey.

April 13, 2022

Exploration of prescribing error reporting across primary care: a qualitative study.

April 13, 2022

Improving the specificity of drug-drug interaction alerts: can it be done?

April 6, 2022

Patient safety when receiving telephone advice in primary care - a Swedish qualitative interview study.

February 23, 2022

Alert burden in pediatric hospitals: a cross-sectional analysis of six academic pediatric health systems using novel metrics.

November 3, 2021

Prescribing errors with low-molecular-weight heparins.

October 13, 2021

CancelRx: a health IT tool to reduce medication discrepancies in the outpatient setting.

September 1, 2021

See More About The Topic

Ambulatory Clinic or Office

Outpatient Pharmacy

Information Professionals

Medicine

Nurse Care

Using sociotechnical theory to understand medication safety work in primary care and prescribers' use of clinical decision support: a qualitative study.

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

Clinician collaboration to improve clinical decision support: the Clickbusters initiative.

Predicting dispensing errors in community pharmacies: an application of the Systematic Human Error Reduction and Prediction Approach (SHERPA).

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Using sociotechnical theory to understand medication safety work in primary care and prescribers' use of clinical decision support: a qualitative study.

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

Clinician collaboration to improve clinical decision support: the Clickbusters initiative.

Predicting dispensing errors in community pharmacies: an application of the Systematic Human Error Reduction and Prediction Approach (SHERPA).

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site