WHAT IS THE EVIDENCE THAT WORKLOAD IS AFFECTING

WHAT IS THE
EVIDENCE THAT
WORKLOAD IS
AFFECTING
HOSPITAL
PHARMACISTS’
PERFORMANCE
AND PATIENT
SAFETY?
Dr Sarah Willis; Dr Rebecca Elvey;
Professor Karen Hassell
University of Manchester
May 2011
What is the evidence that workload is affecting hospital pharmacists’
performance and patient safety?
TABLE OF CONTENTS
Table of contents ................................................................................................................ 1
Executive summary .......................................................................................................... 2
Context .................................................................................................................................. 3
1
Introduction .............................................................................................................. 4
2
Aims and objectives ............................................................................................... 6
3
Methodology ............................................................................................................. 8
3.1
Search strategy ............................................................................................................... 8
3.2
Key words and search terms used ........................................................................... 8
4
Findings .................................................................................................................... 11
4.1
Overview ......................................................................................................................... 12
4.2
Pharmacy workload and what is measured....................................................... 12
4.3
The impact of pharmacy workload on pharmacists’ performance .......... 13
4.4
The impact of pharmacy workload on pharmacists’ well-being................ 13
4.5
The impact of pharmacy workload on patient outcomes ........................... 14
5
Discussion ................................................................................................................ 15
6
Appendix 1 ............................................................................................................... 16
7
References ............................................................................................................... 22
© CfWI | May 2011
1
EXECUTIVE SUMMARY
This paper reviews and then synthesises the published evidence on workload in
the hospital pharmacy setting in the UK. Evidence is reviewed in relation to three
questions:
1.
2.
3.
Has hospital pharmacy workload changed (increased)?
Does workload influence workforce behaviours and attitudes to work?
Does workload affect pharmacists’ performance?
Findings suggest the following:
1.
2.
3.
2
There is limited evidence to show that workload has increased.
Pharmacists’ physical and mental well-being are being affected by their
workload. In particular, workload is perceived as causing job stress and job
dissatisfaction.
High workload is associated with an increase in medication errors.
What is the evidence that workload is affecting hospital pharmacists’
performance and patient safety?
CONTEXT
The Centre for Workforce Intelligence (CfWI) workforce risks and opportunities
project sets out the major risks and opportunities facing the health and social
care workforce in 2011 and beyond. The University of Manchester is providing
specialist knowledge to CfWI through an integrated approach across a range of
disciplines. This is one of a series of briefing papers to provide managers and
workforce planners with evidence to inform their choices when addressing short,
medium, and long-term workforce challenges.
The 2011 series focuses on:
Labour substitution and efficiency in health care delivery: general principles
and key messages
Recession, recovery and the changing labour market context of the NHS
Workforce risks and opportunities: working time practices in nursing and
midwifery
The policy context for dentistry skill mix in the NHS in the UK
Identifying the risks and opportunities associated with skill mix changes and
labour substitution in pharmacy
What is the evidence that workload is affecting hospital pharmacists’
performance and patient safety?
Managing people in networked organisations: identifying the challenges for
health and social care
© CfWI | May 2011
3
1
INTRODUCTION
As the pharmacy profession shifts towards providing a wider range of healthcare
and clinically focused services, pharmacists’ work increasingly involves activities
based on their specialist medicines knowledge in addition to more traditional,
technical tasks related to the supply of medicines. Evidence suggests that this
shift in focus – or the reprofessionalisation2 of pharmacy – while offering
pharmacists opportunities to take on more patient-oriented roles,1 may result in
work intensification,3 conflicting task priorities and increased workload.4-10
Moreover, in terms of the impact of adopting new professional roles on
occupational well-being,11;12 it appears that rising work pressure is associated
with pharmacists feeling unvalued13 and stressed.14 One consequence of this is
that pharmacists may reduce their work hours to cope with stress, or it may result
in pharmacists leaving the profession altogether, with obvious consequences for
labour market supply. Increasing workload or intensification of work has also
been associated with poor performance, perceived or actual, (dispensing errors
for example), thus compromising patient safety.
The expansion in services provided by pharmacists taking place within the
reprofessionalisation2 movement also coincides with a growth in the technical
medicines supply aspects of pharmacy work. This growth can be seen in analysis
of government data on community pharmacists’ dispensing activities
demonstrating a 54 per cent rise in dispensing volume in England and Wales
between 1998/9 and 2007.15;16 While no equivalent national data are available
for hospital pharmacy work, the complexity of hospital patients’ medication
needs (arising from high levels of co-morbidity and from the toxicity of some
drug regimens) means it is likely that activities directly or indirectly involving the
supply of medicines will constitute a major feature of hospital pharmacists’
work.17 Certainly, growth in the number of medicines used per hospital patient
has been cited as contributing to rising workload among hospital pharmacists,18
and this situation is undoubtedly exacerbated by high vacancy rates in the sector,
with inadequate staffing reported as creating pressure among hospital
pharmacists to work intensively.14
It appears, then, that both the nature of pharmacy work and pharmacists’
workload have changed. It also appears that changes in workload have had a
negative impact on pharmacists’ occupational well-being,11;12 and may explain
why many pharmacists describe the daily demands of their work as ‘constantly
4
What is the evidence that workload is affecting hospital pharmacists’
performance and patient safety?
stressful’.19;20 There are also concerns that pharmacists’ workload may be having
a negative impact on the quality of care being delivered to patients.
Given these concerns, and in light of growing opinion within the pharmacy
profession that workload and workload pressures are rising, it is important to
determine whether there is any research evidence that workload is in fact
increasing, and what evidence there is that workload is affecting the
performance or labour market activity of hospital pharmacists, or is affecting
patient safety.
In this review, we therefore set about systematically evaluating research on
pharmacy workload in the secondary healthcare context and its impact on both
patient and employee outcomes. In doing so, we review evidence of workload
where it is operationalised
at job level, which refers to the general demands of a job, the amount of
work done in a day, and the level of concentration needed to get the
work done
at task level, which is more about the specific resources and demands
required to complete a specific task.21
© CfWI | May 2011
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2
AIMS AND OBJECTIVES
The aim of this review is to synthesise the published evidence on workload in the
hospital pharmacy setting in the UK. The effects of UK community pharmacists’
workload have been comprehensively documented in a recent review by one of
the authors (KH) in a paper demonstrating how much community pharmacists’
workload has grown since the introduction of new contractual frameworks that
reimburse pharmacists for performing both new reprofessionalised roles as well
as more traditional technical supply activities.16 As well as providing quantitative
data related to pharmacists’ work activities, Hassell et al’s paper also considers
the extent to which research has established links between changes in
community pharmacists’ workload and a number of outcomes, including
prescribing errors, workforce behaviours, and effects on pharmacists’ wellbeing.16 It appears that while there is an emerging evidence base related to
growth in community pharmacists’ workload, and limited, small-scale material on
workload and its impact on pharmacists themselves, there is a lack of robust
studies establishing links between workload and patient safety outcomes that
take into account confounding factors such as skill mix or the organisational
context in which pharmacists work.
While it has, therefore, been recognised that much of the evidence in community
pharmacy is derived from studies that have limited representativeness, the next
step in determining the extent to which pharmacists’ workload is affecting
pharmacists’ performance and patient safety is to review workload in the hospital
pharmacy setting in the UK. In conducting this review we set the following
objectives:
1.
2.
3.
to investigate evidence that hospital pharmacy workload has changed
(increased)
to explore evidence that workload is linked to hospital pharmacists’
workforce behaviours and attitudes to work (including their labour market
decisions and/or occupational well-being)
to explore evidence related to links between hospital pharmacists’ workload
and pharmacists’ performance (including the impact of workload on patient
outcomes and the implications for patient safety).
A number of outcome measures or effects of workload have been considered in
conducting this review, including job satisfaction, job stress, labour market
withdrawal and reduction in activity.
We have also considered pharmacist performance outcomes, and here we
concentrate on performance related to safe and effective medicines use that
6
What is the evidence that workload is affecting hospital pharmacists’
performance and patient safety?
may be studied in terms of medication errors (and operationalised in studies of
errors in prescribing, dispensing, administering and/or monitoring medicines).
© CfWI | May 2011
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3
METHODOLOGY
In conducting this review we have not followed the methodology for undertaking
a systematic review in the conventional sense; rather, our approach has been to
provide a synthesis of findings from relevant research literatures. We have
attempted to minimise bias by using robust methods in our search strategies,
and by providing detail of inclusion and exclusion criteria so that the review could
easily be replicated and updated in future if necessary.
3.1
Search strategy
A librarian experienced in conducting reviews of health services research
conducted the literature search, with the following electronic databases
searched from 2000 onwards:
The Cumulative Index to Nursing and Allied Health Literature (CINAHL)
International Pharmaceutical Abstracts (IPA)
Medline
Embase
British Nursing Index (BNI)
Scopus.
3.2
Key words and search terms used
Given the difficulty in defining workload search terms reported by Hassell et al16
we used diverse terms to identify relevant material. Moreover, in order to
complement the work undertaken on community pharmacists’ workload we
used many of the same search terms, but adapted them (where relevant) to the
hospital setting. Search terms used in conducting this review relate to four
categories:
contextual or hospital-setting terms
terms referring to workload
terms describing the pharmacy workforce
terms designed to capture literature reporting outcomes of workload
See Table 1 for further details. A UK filter was applied to remove studies
conducted outside the UK.
8
What is the evidence that workload is affecting hospital pharmacists’
performance and patient safety?
Table 1: Search terms used in electronic databases
Category of search term
Terms used
Contextual terms
Hospital pharmacy*.tw
(hospital adj 6 (pharmacy or pharmacies or pharmacist or
pharmacists))
Exp Pharmacy Service, Hospital/
Exp Pharmacies/st,ut
Workload terms
Exp Workload/
*Task Performance and Analysis/
Workflow*/tw
Workload*.tw
“workload measure*”.tw
“work measure*”.tw
“work intensification”.tw
“work condition*”.tw
“work pattern*”.tw
“work outcome*”.tw
“work activit*”.tw
“work assignment*”.tw
“dispensing load*”.tw
“dispensing volume*”.tw
“Staff* level*”.tw
Productiv*.tw
Workforce terms
Exp Pharmacists/ut
Pharmacy staff
Outcomes of workload terms
Error
Mistakes
Adverse events
Patient safety
(job) satisfaction
well-being
pressure
Following the approach used in Hassell et al’s review of community pharmacy,16
this review was not restricted to any particular study design. We wanted to
include a range of study types, using appropriateness as a condition for inclusion.
Instead of using a hierarchy of evidence where randomised controlled trials are
considered the ‘gold standard’ against which other research study types are
compared, in this review the relative value of research evidence was assessed
during the process of evidence synthesis. Quality criteria were applied to restrict
evidence included in the review to peer-reviewed, empirical primary research.
© CfWI | May 2011
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Where a conference abstract had also been published as a full, peer-reviewed
paper, we only included the full paper, as this was deemed to be of higher quality.
Inclusion criteria were applied to the results of the search strategies so that
studies of workload in the hospital setting per se were included, but studies that
considered one of the outcome measures without explicitly investigating how it
related to workload were excluded. Table 2 provides further detail of criteria
applied in conducting the review.
Table 2: Inclusion and exclusion criteria
Category
Include in review if ALL met by Exclude from review if ANY
a study
met by a study
Setting
Hospital pharmacy
Community pharmacy; health
centre
Location
UK
Outside UK
Design/study type
Any empirical study
Non-empirical study;
methodological paper
Publication type
Peer-reviewed journal papers;
peer-reviewed conference
abstracts
Letters; non-peer-reviewed
articles/reports
Publication date
2000–2011
Pre 2000
Focus of study
Workload and/or its impact
Studies addressing outcomes
without exploring how related to
workload
The inclusion/exclusion criteria were applied during two stages of the review
process. Firstly, they were applied to the title and abstract of a paper, with those
papers not meeting ALL the criteria excluded. Where inclusion criteria were met,
or where it could not be determined from reading the title and abstract whether a
study met ALL the criteria, full papers were then retrieved. On reading these,
criteria were applied again.
For rigour, two of the authors (SW and RE) reviewed titles and abstracts and
independently applied inclusion and exclusion criteria. Results of this process
were compared. At this stage, both authors included and excluded the same
studies.
Using a data extraction tool, key features of all the studies meeting the inclusion
criteria for this review were recorded (see Table 3 in the Appendix).
10
What is the evidence that workload is affecting hospital pharmacists’
performance and patient safety?
4
FINDINGS
The initial search strategy identified 290 papers once duplicates had been
removed. After the inclusion/exclusion criteria had been applied to titles and
abstracts, 231 citations were excluded, mostly because they were either not
reporting empirical work, or related to studies conducted in settings other than
hospitals, or outside the UK. Copies of 59 full papers were obtained for full
consideration, after which a further 48 were excluded.1
A hand search of the bibliography from a review paper on the incidence, type and
causes of dispensing errors was also undertaken, together with a search of key
authors. This resulted in a further five papers being included in the review.22-26
Figure 1 summarises the results of this review process.
Figure 1; Flow chart of review process
1
Key features of the papers included in this review can be found in Table 3 in the Appendix
© CfWI | May 2011
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4.1
Overview
Of the 16 papers we reviewed, it is notable that few papers had workload and its
impact as their primary focus. Moreover, although nine of the papers used
objective, quantifiable measures of workload – comparing, for example, rates of
items dispensed with dispensary error rates – two of these papers relied on
subjective, qualitative perceptions of workload derived from a small number of
interviews27, or contained limited detail about the study and its findings.28
However, some studies were larger in scale. Of particular note is a study of
measuring dispensing workload (as items/person/hour) at 17 non-specialist
hospital pharmacy dispensaries in Wales.29
4.2
Pharmacy workload and what is measured
Workload was defined and measured differently across the studies reviewed here.
That makes it difficult to compare results across studies and/or to determine the
extent to which hospital pharmacists’ workload may have increased. Several
studies included in our review quantified workload in relation to dispensing
activity – a postal survey of oncology dispensing workload across Britain
measured the number of cytotoxic IV chemotherapy doses prepared each
month, and found that oncology dispensing workloads had increased over the
five years to 2003 by an average of 178 per cent (although this measure of
increased workload was self-reported by pharmacists taking part in the study, and
so should be treated with some caution).30 A larger-scale study collating data
from hospital dispensaries across Wales found that on average 9.9 items were
dispensed per person per hour, but this study aimed only to provide a benchmark
of workload and did not measure change in workload over time. 29
Two studies considered workload in relation to service reconfigurations, and
report less than positive findings. In an evaluation of whether introducing a wardbased technician reduces pharmacists’ workload, the number of non-stock item
requests made to pharmacists was used to measure workload.31 Since requests
were found to increase after introducing the new service by 14 per cent – and
hence pharmacists’ workload was viewed as having increased by the same
amount – findings suggest that skill-mix initiatives aimed at redesigning ward
supply services in order to make better use of pharmacists’ clinical knowledge
may result in work intensification for pharmacists. Another study, this time of a
pharmaceutical care intervention promoting self-medication on a paediatric
ward, found that there was no net gain in workload after redesigning pharmacy
12
What is the evidence that workload is affecting hospital pharmacists’
performance and patient safety?
services, as workload shifted from the dispensary to the ward but was not
reduced overall.32
4.3
The impact of pharmacy workload on pharmacists’ performance
Six studies evaluated in this review investigated the impact of workload on
performance, in relation to medication errors. Studies tended to use qualitative
methods (interviews) to provide insight into the causes of error in order to throw
light on quantitative data on medication errors.
In terms of pharmacists making dispensing errors, there is some evidence to
suggest that interruptions, distractions, lack of staff, inadequate skill mix, being
busy, and time restraints contribute to errors.23;24;33-35 In this context, it is
important to note that causes of errors in the literature tend to be recognised as
multi-factorial, with high workload mentioned most frequently, although low
workload was also linked to error by one study.35 High workload has also been
linked to the likelihood of a pharmacist identifying an error when checking
patient drug charts: where workload was high, fewer errors were identified.36
4.4
The impact of pharmacy workload on pharmacists’ well-being
Studies of workload that described workers’ subjective experiences of work
demands (n=5) in the main employed qualitative methods to explore the nature
and impact of pharmacy work and workload on pharmacists.24;27;28 We found that
unmanageable work demands (caused by interruptions and being pressurised to
hurry, as well as understaffing in the dispensary) were associated with a number
of pharmacists’ well-being outcomes, most typically physical and mental stress,
that on one occasion was also linked to job dissatisfaction.28
Similar findings of the impact of workload on pharmacists – that interruptions,
staff shortages and workload make an important contribution to pharmacists’ job
stress – was also reported by a quantitative study of work stressors.37 We also
found quantitative evidence that, as a consequence of high workload,
pharmacists were increasingly likely to experience repetitive strain injury
problems.30
© CfWI | May 2011
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4.5
The impact of pharmacy workload on patient outcomes
A considerable amount of research on dispensing errors in hospital pharmacy has
been conducted, and this tends to focus on quantifying dispensing errors38 or on
the type of error made (in terms of wrong drug, wrong strength of drug, etc.) or
on who identified the error39. There is, in addition, a growing body of evidence
addressing the causes of errors, and as we reported above (in relation to
pharmacist performance outcomes) workload is often a key variable in explaining
dispensing errors.
Alongside affecting pharmacists’ performance, in this review we identified nine
papers linking errors to patient outcomes, although in many instances (5/9) this
impact on patients was implied by findings in terms of errors being harmful to
patients in general rather than in terms of how serious an error was for patients.
There were, however, a number of papers that did classify errors in terms of the
severity of risk they presented to patients.25;26;40
14
What is the evidence that workload is affecting hospital pharmacists’
performance and patient safety?
5
DISCUSSION
From this review, it is clear that measuring workload in hospital pharmacy and its
outcomes is often undertaken in the context of researching quality and safety in
medicines use. This should be no surprise, given the medicines focus of the
pharmacy profession. However, investigating workload in relation to error rates
may not reflect the complexity or difficulty of pharmacists’ work or what is
involved in completing a task (interruptions, enquiries, etc.) at a job-level rather
than at a task-level of analysis.
Studies that focus on relationships between multiple variables are an obvious
omission from the literature. Such studies would make it possible to determine
whether errors attributed to workload are more or less likely to cause harm to
patients (that is, are more serious) than incidents caused by other factors. There
is also a lack of research providing robust evidence (that does not derive from
qualitative studies of perceptions) in investigating the impact of workload on
pharmacists’ well-being.
Questions of
whether pharmacy workload in the secondary healthcare context is rising
the impact of pharmacy workload on both patient and employee
outcomes
cannot, therefore, be addressed by the existing research literature. Further
research is needed to explore these important topics in more depth.
© CfWI | May 2011
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APPENDIX 1
Table 3: Key features of papers included in this review
Study
Method and subjects
Study aim
Outcome
measure(s)
Main findings
22
Anto et al:
Int J Pharm Pract
2010;18:122-4
Qualitative: 10 interviews
with staff involved in
labelling errors.
To evaluate causes of
dispensing-label errors.
Causes of error.
Under-staffing during lunch identified as a source of
workload pressure leading to label-generation errors. A
busy environment and distractions also contributed to
errors.
35
Armitage et al:
J Eval Clin Pract
2010;16:11891197
Quantitative and
qualitative: Retrospective
analysis of a sample of
error reports submitted
1999-2003 at one
hospital. Follow-up
interviews with doctors,
nurses and pharmacists
(n=40).
To improve reporting of
and learning from drug
errors; to investigate
factors contributing to
errors.
Error type, location,
contributory factors.
Interruptions and stress had the lowest frequencies of
contributory factors identified in quantitative analysis
(1.31% and 1.72%) – workload not reported as a factor.
Qualitative data demonstrated that error causes were
viewed as multi-factorial, with high workload
mentioned most frequently, although low workload was
also seen as precipitating error. Error prevention
believed to rest on reforming working practices rather
than about increasing resources or adjusting volume of
work.
41
Quantitative analysis of
national aseptic error
reporting scheme (NAERS)
error data. Self-reported
errors & (potential)
severity of errors Jan-Dec
2007 from 43 UK
hospitals.
To identify factors
Details of errors
contributing to
(type, severity etc);
pharmacy compounding contributory factors.
errors.
Bateman &
Donyai: Qual Saf
Health Care
2010;19(5):1-6
16
The highest rated factor was 'individual staff error';
(78%) - second highest was 'distraction/interruption’
4.3%);'workload above planned capacity' and 'staffing
level below establishment' 4th and 5th (3.2 and 3.1%).
Reduced staffing & workload above capacity especially
contributed to errors with parenteral nutrition
products.
What is the evidence that workload is affecting hospital pharmacists’
performance and patient safety?
Study
Method and subjects
Study aim
Outcome
measure(s)
Main findings
23
Beso et al:
Pharm World Sci
2005;27:182-190
Quantitative and
qualitative: Analysis of
recorded dispensing
errors identified at the
final check stage over two
weeks (weekdays only) in
June and a further 7 weeks
during July-September
2002; dispensing errors
reported outside the
pharmacy department
examined for June
fortnight & all of 2002.
Interviews with staff on
perceived causes of errors
(n=27).
To determine the
frequency and types of
dispensing errors; to
explore perceived
causes of errors.
% dispensed items
for which one or
more errors
occurred at the final
check stage; %
errors reported
outside pharmacy
department;
perceived errorcausing conditions.
One or more dispensing errors identified at final check
stage in 2.1% of 4849 dispensed items, outside the
pharmacy error reporting accounted for 0.02% of
dispensed items. Error producing conditions most
frequently identified as related to workload (being busy,
time restraints, being shortstaffed). Distractions,
interruptions, working conditions, dispensary design
(environmental factors) also commonly cited, as were
stressors (impacting on morale / physical health /
performance). Difficulty in managing the workload
resulting from enquiries was considered a contributory
factor.
31
Quantitative: Data on
errors and workload
collected for two weeks
before and two weeks
after introduction of new
technician service to five
wards (two acute
admissions and three
elderly) with perceived
high workload at Bristol
Royal Infirmary in 2001.
To determine if having a
ward-based technician
service reduces
medication
administration errors
and/or pharmacist
workload.
Incidence of
unavailable
medication
administration
errors (U-MAEs);
frequency of calls to
pharmacy; volume
of weekend
medicine supply;
workload of
pharmacist
measured via
number of nonstock item requests.
U-MAEs and calls to pharmacy reduced, & overall item
requests during weekend reduced by introduction of
ward-based technician service; pharmacist workload
(requests for non-stock supply) increased for acute
admissions-related work but declined in relation to
care-of-the-elderly-related work.
Conroy et al:
Int J Pharm Pract
2002;10:171-5
© CfWI | Month Year
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Study
Method and subjects
Study aim
Outcome
measure(s)
Main findings
27
Eden et al:
Int J Pharm Pract
2009;17:181-7
Qualitative: Interviews
with recently qualified
pharmacists (n=12; only
n=3 working in hospital
pharmacy).
To explore why
pharmacists leave or
intend to leave
profession.
Perceptions of work
and workload, job
satisfaction, stress.
Dissatisfaction with workload pressures influences
workforce behaviours (decisions to leave the
workforce).
28
Ferguson et al:
Int J Pharm Pract
2009;19:B2
Qualitative: Interviews
with hospital pharmacists
(n=15) exploring aspects
of workload associated
with job dissatisfaction
(n=26 pharmacists
interviewed for study).
To explore aspects of
pharmacists' job
dissatisfaction.
Perceptions of
workload and work
pressure; job
dissatisfaction.
All pharmacists expressed dissatisfaction with workload;
understaffing, work intensification, working conditions
and stress / pressure contribute to job dissatisfaction.
29
Hiom et al:
J Clin Pharm &
Therapeutics
2006;31:357-62
Quantitative: Measure of
dispensing workload
(items/person/hour)
collected for 3 days from
17 non-specialist hospital
pharmacy dispensaries in
Wales in2002.
To develop / benchmark Dispensing activity dispensing rates.
items/person/hour.
Influence of hospital
size, skill mix,
telephone
interruptions on
dispensary activity.
Average dispensary rate was 9.9 items/person/hour.
Dispensary activity was not significantly correlated to
hospital size; dispensing rates were higher with
increased % pharmacists & technicians, lower with
increased % ATOs.
25
James et al:
Int J Pharm Pract
2008(a);16:17588
Quantitative:
Retrospective analysis of
unprevented dispensing
incident data reported to
UKDEAS (UK Dispensing
Error Analysis Scheme) Jan
2003-Dec 2004 for all
hospitals in Wales (n=20) .
To monitor unprevented
dispensing incidents by
type & drugs involved; to
identify contributory
factors.
Frequency and type
of dispensing
incidents; drugs and
dosage forms
associated with
incidents; patient
outcomes; causes.
Overall unprevented dispensing incident rate was 16
per 10,000 items dispensed; contributory factors were
reported for 484 (48%) of these, with high workload
cited in 141 incidents, low staffing in 74 and being a
lone worker in 10. Patient outcomes of errors are
reported (although not linked to workload).
24
Qualitative and
quantitative: interviews, a
focus group, observations
To evaluate the causes
of prevented dispensing
incidents for drugs at
Frequencies of
prevented
dispensing incidents
24 incidents were reported at 10 hospitals. High
workload reported in 14 incidents, and inadequate
staffing in 5 incidents. Physical and mental stress
James et al:
Int J Pharm Pract
2008(b);16:239-
18
What is the evidence that workload is affecting hospital pharmacists’
performance and patient safety?
Study
Method and subjects
Study aim
Outcome
measure(s)
Main findings
49
and literature review used
to design tool for
collecting data on
prevented dispensing
incidents from hospitals in
Wales (n=16) for four
months in 2006.
Dispensary workflow data
also collected.
high risk of dispensing
incidents.
and their causes.
associated with high workload, interruptions and
inadequate staffing were also reported as errorcontributing factors or conditions.
40
James et al:
Int J Pharm Pract
2011;19:36-50
Quantitative: Comparison
between unprevented and
prevented dispensing
errors at 5 Welsh hospitals
over 3 months in 2005.
To compare between
the rate, type and
causes of prevented /
unprevented dispensing
incidents.
Frequencies of and
differences between
prevented /
unprevented
dispensing
incidents; causes of
errors compared.
35 unprevented (0.016% of items dispensed) and 291
prevented dispensing incidents (0.13%) were reported.
Contributory factors were reported for 171 of the
prevented and 25 of the unprevented incidents (59%
and 71% respectively). High workload was cited in 21%
of prevented and 29% of unprevented incidents, low
staffing, interruptions, urgent deadlines and being a
lone worker were also reported. There was no
significant different in the proportion of unprevented
and prevented dispensing incidents attributed to each
contributory factor. Low workload was cited as a factor
for one prevented incident. No patient experienced
harm after taking drug associated with unprevented
dispensing incidents.
37
Quantitative: Postal survey To determine levels of
of pharmacists in
job satisfaction and
Northern Ireland
work stressors.
(766/1965, 39%
responses).
Level of job
satisfaction; levels of
work stress
associated with 5
domains (managing
workload was 1
Interruptions, workload, staff shortages perceived as
main sources of work stress.
McCann et al:
Pharm World Sci
2009;31:188-94
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Study
Method and subjects
Study aim
Outcome
measure(s)
Main findings
domain).
26
Roberts et al:
Int J Pharm Pract
2002;10:R6
Quantitative: Analysis of
dispensing error reports
submitted by chief
pharmacists from 89
hospitals in England,
Wales and Scotland 19912001.
To determine type of
prescription & type of
error, drugs / staff
involved; causes and
outcomes of errors.
Types of dispensing
errors; causes and
outcomes of errors.
10 drugs are most commonly involved in dispensing
errors. Of 7158 error reports received, contributory
factors were reported for 5026, high workload/low
staffing was reported for 1,156 (26%). Moderately
detrimental effects were recorded for 291, serious
detrimental effects for 26 and fatality for 1.
30
Summerhayes:
J Oncol Pharm
Practice;2003;9:1
23-8
Quantitative: Postal survey
of pharmacist members of
the British Oncology
Pharmacy Association and
nursing colleagues
(54/104, 51.9%
responses).
To determine extent of
change in IV
chemotherapy
workload; availability of
pharmacy and nursing
staff to carry out this
work.
Number of cytotoxic
doses prepared per
month; number of
patients for whom
chemotherapy is
prepared per week;
workload trends;
staff stress;
treatment waiting
times.
Mean number of cytotoxic doses prepared per
month=896, mean patients having prepared
chemotherapy drugs for each week=92.7; 43/46
pharmacists reported an increase in workload over five
years of an average of 178%. Consequences of rising
chemotherapy demand included inability to carry out
other aseptic dispensing work; increased staff repetitive
strain injury problems; strained working relationships
between pharmacy and the rest of the oncology team.
32
Tomlin &
Saunders: Paed
Nurs;2001;
13(4):25-9
Quantitative: Evaluation of
pre- and postpharmaceutical care
intervention promoting
self-medication on a
paediatric ward.
To determine whether
intervention reduced
workload and errors.
Dispensary
workload;
dispensing time;
errors; cost;
turnaround time;
patient /carer
satisfaction.
Workload shifted from dispensary to ward but was not
reduced; turnaround time drug errors, medication costs
were reduced. High levels of satisfaction with the new
service reported by carers/patient /nurses.
36
Quantitative: Analysis of
prescribing errors
recorded by 39
pharmacists on ward visits
on 38 randomly selected
To investigate the
prevalence of
prescribing errors and
factors influencing
identification by
Proportion of new
medication orders
with a prescribing
error; predictors for
error detection
Drug chart checking workload was the strongest
predictor of prescribing error identification. Errors were
16% less likely to be identified on Fridays than any
other day of the week.
Tully & Buchan:
Pharm World Sci
2009;31:682-8
20
What is the evidence that workload is affecting hospital pharmacists’
performance and patient safety?
Study
37
McCann et al:
Pharm World Sci
2009;31:188-94
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DRAFT # CONFIDENTIAL – footer
Method and subjects
Study aim
Outcome
measure(s)
days between Mar 2003
and Aug 2005 at a
teaching hospital in
England.
pharmacists.
included checking
workload (measured
as the number of
patients' drug charts
examined per day)
Quantitative: Postal survey To determine levels of
of pharmacists in
job satisfaction and
Northern Ireland
work stressors.
(766/1965, 39%
responses).
Level of job
satisfaction; levels of
work stress
associated with 5
domains (managing
workload was 1
domain).
Main findings
Interruptions, workload, staff shortages perceived as
main sources of work stress.
21
7
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