Table 2

Set of Basic Problem Factors identified empirically from the narratives

Basic Problem Factor	Lower-level codes	Example from narratives
1. Staffing	Absences Staff shortage Inappropriate skill mix	‘It was just one of those days where I felt I wasn't getting anywhere, we were short staffed due to sickness and annual leave, the phones never stopped, and sometimes I think I am the only person who can hear them ringing’
2. Demand management and workload	Concurrent activities Exceptional increase in demand Queue building up No time allocated to paperwork	‘Then I was trying to train a new girl, but with no support to answer the phones or the hatches we were constantly interrupted, so I was losing my train of thought, and she was losing her concentration, and with the work we had to try and get through it was quite unnerving for her’
3. Training	Training conflicting with other priorities Interruptions to training Staff inexperienced/not fully trained	‘The majority of dispensers are inexperienced and still learning; therefore we need the TTO endorsements to be clear. I then have to go back to the dispenser and ask them to change what they've dispensed—more duplication of work!’
4. Equipment & IT	IT design inappropriate IT interaction problem Stock-keeping problems Unavailable/malfunctioning equipment	‘Tracker (log of prescriptions arrived, dispensed and completed in pharmacy) consistently going down so couldn't get information for ourselves or ward on the state of TTOs’
5. Teamwork and attitudes	Negative attitude towards work Communication style during conflicts No consideration for implications on others Reluctance to take on unallocated tasks	‘The pharmacist was quite angry that it had taken me so long to do!’
6. Work environment	Insufficient space Messy/untidy work environment Frequent interruptions	‘Folders left out and bits of labels all over work bench made work difficult as no space. Leaflets, meds and bits of labels, etc do get left on bench, but it happens when we are busy, and everybody has different ways of working, but it can be very untidy sometimes.’
7. Safety culture and acting on known problems	Issues not addressed straight away Recurrent problems not resolved Unjust blame Not seeking clarification (individual)	‘I asked the dispenser why they had labelled the box as one twice a day when this was not endorsed anywhere on the prescription. They said that they did what they thought was right.’
8. Procedures	Absence of procedure Awareness of procedure (external) Awareness of procedure (internal) Inappropriate procedure Procedure not followed	‘Plus I had two patients who phoned to say that they had not received enough medication from us on their outpatient prescriptions. In both cases, the doctor had requested patients to have 6 weeks, but we had only given 4 weeks. When I explained we only supply 4 weeks from the hospital, they were rather miffed as they […] were not told about this. Are the outpatient clinic doctors aware of our 4-week policy? And is this information displayed anywhere so patients are aware?’
9. Job description and allocation of responsibility	Inadequate allocation of responsibility Allocation of responsibility unclear	‘Just before lunch, I noticed the clinical check tray was full to overflowing, only had one technician, and they weren't “medicines management”-trained. I wondered how come there were so many TTOs. Couldn't they have been dealt with on ward visit and saved dispensary pharmacist the job?’
10. Communication and information	External communication inadequate Internal communication inadequate Missing information	‘EDS came up to pharmacy, and a pharmacist had recorded that most of what the patient needed was at the community hospital (where the patient was being transferred to), but there was no community hospital name on the prescription. I rang the ward to find out which hospital, and the ward said they were actually going to a nursing home. I think there was a misunderstanding on the ward before the EDS came up to pharmacy.’
11. Management of change	Implications of change not considered New failure modes introduced (IT) Not prepared for regulatory change	‘Also prior to EDS (paper copies of TTOs were used), any TTOs for patients going to a community hospital the ward staff were to liaise with the hospital about which items were required to be dispensed. With EDS, this doesn't happen, and the clinical checker may not notice. The dispenser is then on occasions dispensing unnecessarily. These TTOs are also more likely to be on transport.’

EDS, Electronic Discharge Summary; TTO, To Take Out (discharge prescriptions).