Abstract
In the year 2000, the United Kingdom government produced a report called “Organisation With a Memory” in response to the problem of safety in the healthcare sector and committed to reduce the number of serious medication errors. Whilst patient safety research in other healthcare settings such as the primary and secondary care has been under way for the past two decades, patient safety research in care homes has largely been neglected. The increasing age of the general population in the UK also motivates the need to understand the problem of patient safety, particularly medication safety in the care home. The review of the care home medication safety literature found that it was difficult to construct a view of the care home medication system and the extent of the problem of medication errors in care homes in England. This thesis presents the findings of the first large-scale epidemiological study of the prevalence and types of medication errors in England that was conducted as part of a wider study. A total of 31 residents in seven care homes were studied for prescribing, monitoring, dispensing and medication administration errors. Each type of error was detected using different methods. The study found six in ten care home residents experienced at least one medication error. Dispensing and medication administration errors were the most common medication errors identified in the study. To understand the causes of errors and derive recommendations for system improvements, an established systems analytical framework, The London Protocol, was used. However, the limitations of the analytical framework particularly the lack of context and relationships between the error contributory factors in the framework led to the exploration of other methods for analysing work systems. The feasibility of a commonly used task analysis method, hierarchical task analysis (HTA) to analyse complex healthcare systems was explored. An HTA of medication provision in a hospital was performed. However, it was difficult to represent the complexities and variability of medication provision in the hospital using the HTA. A formative approach to analysing complex systems was advocated and the potential of cognitive work analysis (CWA) was explored. Work domain analysis is the first of five analysis phases in CWA and was used to analyse the care home medication system for the first time. The resultant model of the care home medication system, the abstraction hierarchy (AH), provided a systems view of the whole care home medication system. It was the first time that the care home medication system was represented this way. The AH provided a knowledge base of the care home medication system and was also used as an error analytical framework. A novel method for analysing the errors was developed. The same medication errors identified in the epidemiological study was analysed using the AH. It was the first time that two different methods, namely The London Protocol and the AH were used to analyse the same care home medication errors. A comparison of their advantages and disadvantages was made and the AH was found to be a more suitable method for analysing errors than The London Protocol because the means-ends links in the AH guided the analyst to identify different work categories that contributed to the medication errors. The AH also provided information about the work system that was important for analysis and the generation and evaluation of recommendations for system improvement. Finally, the thesis discussed future research and developments relating to error identification and analysis, methods for understanding complex healthcare systems and the use of CWA in healthcare.