My parents, as they often do, came up to Newcastle and stayed for a few nights last week, and it ended up being a case study in Patient Work.
My mother left all her medications at home. I’m sure she’s not the first, and won’t be the last person to make this kind of skill-based error known as a “lapse”, but it immediately raised some obvious questions and issues that she, and others, had to go about solving, requiring significant amounts of time and mental effort which all contributed to her Patient Workload.
- What medications is she on?
- Are any of them shared with Dad and can she just take some of his instead?
- How important are the medications and can any of them be safely skipped until she got back home?
- If she did need to take them, how would she get hold of them?
- Is it safe (& ethical!) for me to prescribe her medications, especially given they are outside my area of specialty?
- Try and visit a GP or medical centre in Newcastle?
- Ring her GP or pharmacy in Sydney and ask their advice and the possibility of faxing or emailing a script to Newcastle?
In the end, she spent a fair bit of time on the phone speaking to her GP and pharmacist in Sydney, who then faxed up the scripts so they could be filled up here. Apparently though, in order for the scripts to contribute towards the PBS Safety Net, the originals then had to be posted up, officially processed, and then posted back to Mum!
Given that this sort of experience is likely to be relatively common, there must be a better way to handle this sort of situation. Sure, there are things that could be improved at the patient end such as some reminder system or checklist prior to travelling that included making sure you have your medications with you. But an important aspect of HF/E is that you need to assume that these kinds of errors will occur from time to time, no matter what error prevention strategies are in place, and design the system as a whole so that it is resilient enough to cope with these incidents and continue functioning despite them, or at the very least reducing their impact.
So as I thought about this episode, one thing that struck me was the fact that the solution involved the use of faxes and Australia Post. This seems remarkable in this day and age. Why not have some kind of “Digital Prescription”, where instead of writing out a script and giving it to the patient to be lost, left behind or as is often the case left with their usual pharmacist, their script is stored digitally and can be accessed by pharmacists anywhere in the country, as well as by the patient from their smartphone or computer. The system could also be set up to provide reminders to the patient about when they need to fill their next script or get a new one from their GP.
As I thought about this concept, it occurred to me that surely someone must already be trying to do this kind of thing, and lo and behold, a quick Google search showed that such a system is already available in Australia in the guise of “Electronic Transfer of Prescriptions“! I’m not yet sure of the specifics of the system, but it looks promising.
This highlights another common barrier to improving these kinds of complex systems and removing safety threats and inefficiencies, in that very often solutions exist but they are not widely promoted or aren’t implemented for one reason or another. We certainly need to get better at sharing these stories and our “lessons learned”. But at least, in this case, no harm was done other than time and effort wasted, and it has provided yet another topic for me to start digging into!