Table 4.

Electronic prescribing routines

Routines involving the printed copy of the electronic prescription	Examples from fieldnotes and interviews
Refreshing the screen, printing out newly arrived prescriptions, leafing through the printouts to organise the workflows and routines: Does everything look in order? Any obvious anomalies? Anything urgent? Anything need to be ordered for the next day?	When he’s not serving at the counter, Mahendra, the pharmacist, is at the dispensary computer dealing with prescriptions. He has refreshed the screen and printed out a batch of prescriptions. As he processes each prescription on the computer, he puts the paper prescription in a red plastic basket with labels which he’s also printed out: a bag label and a label for each medicine prescribed. At this point he may also order any medicines needed. He stacks prepared baskets on top of each other. This pile of baskets waits for a dispenser to take a basket, pick and select the required drugs, before handing back to Mahendra to do the final check and bag up the medicines. (Fieldnote, Poppy, 25/03/2019, NF)
	With a pile of freshly printed out prescriptions, Sameer, the pharmacist, explains that you can’t just sort them by patient and put them in the basket for the dispensers to start processing, because there might be urgent ones that need to be processed straight away. Instead, you ‘have to sift through to see what is important.’ After visually scanning each prescription, he has identified three prescriptions which need processing first. One is for a rescue pack for a COPD patient; an acute situation as the patient will want the drugs today. Another acute case—a urine infection. The third one is for meal replacement drinks. These will need to be ordered today so the patient can get them tomorrow. Sameer continues with his explanation ‘so I put these ones (the thicker pile of the recently printed prescriptions) behind this lot (a pile of prescriptions already in the grey basket) because they came through last and then I put these three (the urgent ones) on top because they are important.’ (Fieldnote, Willow, 09/01/2019, NF)
	Shabnam is now going through the pile of recently printed electronic prescriptions. She is sorting through them at speed and putting certain ones to one side. She explains that she ‘tries to take out the bigger ones, leave the easier ones for the others to do ‘cos I’m more experienced’ and they can do the easier ones in between dealing with ‘waitings or collections’. (Fieldnote, Willow, 10/01/2019, NF)
Paper prescriptions can easily move about the pharmacy and be transferred from one member of staff to another to complete a dispensing routine	Mo took a small yellow card marked ‘Willow pharmacy’ at the top of which was a sticker with a patient’s name and address details. He looked in the black filing cabinet under the relevant patient’s surname, pulled out a prescription then put a box of multivitamin tablets and the prescription into a small, red, plastic basket. He went to the front counter and I heard him explain that ‘there is only one’. He then returned to the black filing cabinet, found another green prescription marked ‘repeat dispensing’ and made up another small red basket containing the script and a box of emollient, and took this to the front counter. Linda took over, taking hold of the basket. Mo moved quickly round the corner to dispense some methadone in the supervision corner. I realise I am once again a bit perplexed about this apparently simple transaction—and am yet to fully grasp the path of prescriptions around this front counter area. The problem is that it is so fast moving and the routines are so tacit and collectively embodied that nothing much is said and opportunity to ask them to explain is limited by the frenetic nature of the environment. I wonder how Nina is managing with this as clearly we do need to grasp the path of a prescription request from the front counter to the dispensing of medicines. Mo had disappeared and I had lost my ‘shadowee’… (Fieldnote, Willow, 03/01/2018, DS)
	Mo hands a prescription over to Rashida part way through its preparation asking her to ‘take over please’ - a quiet negotiation met with no resistance and a seamless transfer of a task part way through. Mo says to Ali, who’s recently arrived for his shift, ‘we need to check the orders’. Ali lifts up a heavy crate of medicines from the floor and they both go to the back of the pharmacy. (Fieldnote, Willow, 03/01/2018, DS)
Prescriptions filed for collection act as a record to check the right patient has the right drug	All four pharmacies implemented similar process for patients to pick up their medicines. This description from Foxglove denotes how it’s done: After checking the medicines in the basket with the medicines listed on the prescription, Zane, the pharmacist bags up the medicines and seals the bag with a pharmacy bag label. The prescription is put in a white plastic basket that will go through to the front counter for filing alphabetically by patient’s surname in a drawer under the counter. When a patient comes in to pick up a prescription the staff search through this filing system for the prescription. Aiza tells me the most important thing to check is the patient’s address: ‘so many patients here have the same name.’ Sameer, at Willow also echoed this point: there are so many people with the same name at the pharmacy that staff ‘can’t go on name. I don’t care if (a patient) can’t speak English. If you can’t say your address you won’t get your prescription.’ He draws my attention to the reminder notes stuck to the collection drawers instructing staff to search on address first and to match the bagged up drugs to the prescription. (Fieldnote, Foxglove and Willow, 10/01/2019, 16/01/2019 & 24/01/19, NF)
The prescription becomes part of a multi-faceted checking process, alongside a master document and the dosette box itself	Anjali, a pharmacist, takes me through the dosette checking process. She starts with the MAP—a paper record of which drugs the patient is on and at which time points during the day they should be taken. She reiterates that ‘if any changes happen, changes must be noted down on the MAP by hand’ The next thing is to check the prescription with the MAP, but ‘the MAP is gospel’. Anjali explains the next step is to ‘go down the MAP and tick off on the prescription if the drugs are on the MAP. It’s also a double check on the labelling process.’ While I’m doing this, says Anjali, I also check on the doses etc. Once these checks have been done, Anjali puts the prescription away in the basket that belongs to the patient whose dosette she is checking, before she can begin to check the capsules and tablets in the dosette box. (Fieldnote, Lilac, 14/03/2019, NF)
	There were two people working in the dosette area on my arrival—Saleem, the second pharmacist on ‘checking’ and Nadira, an apprentice technician. Saleem inspects a dosette, flicking his finger underneath to make the tablets jump and rotating it at various angles to inspect inside the individual cells. He then signs line by line against each medication on the printed lists stuck into the dosette box cover. This one had ‘no complications.’ The dosette area is a narrow rectangular room with counter down the left hand side as you enter from the dispensary. Saleem is on the right hand side of the room, standing up and perched behind a stack of green crates all containing dosettes that need checking. Saleem tells me that he first checks the prescription against the ‘card’ (a plastic wallet containing a printed Word document with the patient’s name, medicines, medication review date). This is also stored in electronic form on the computer. Having established that the card and the prescription are the same, he then checks the contents of the dosette box. He explains that the dosette box, the card and the prescription need to agree with each other. My sense is that ‘the card’ is the working or master document in guiding their practices around checking and making up the boxes. (Fieldnote, Foxglove, 05/11/2018 DS)