This paper contributes to critical organizational historiography and the development of ANTi-History through analysis of the history of a major event in the development of Air Canada. We contend that an important gap in ANTi-History is the explanation of the point where decisions occur (i.e. understandings of the micro-processes involved in enrollment, network establishment and the production of knowledges of the past). To deal with the lacuna, we draw on insights from Critical Sense-making in the performance of our historical analysis -undertaken through a seven-step process of moves. We identify not only the need to understand the role of sense-making in network formation and the production of knowledges of the past, but also the role of actants that transcend human and nonhuman actors in influencing behavior (i.e. noncorporeal actants).
Background: Quality-related events are defined as medication errors that reach the patient (e.g., incorrect drug, dose and quantity), in addition to medication errors that are intercepted before dispensing (i.e., near misses). The aim of this study is to quantify and characterize such events as reported by community pharmacies in a Canadian province. Methods: A retrospective analysis was conducted on quality-related events reported to the Community Pharmacy Incident Reporting system from 301 community pharmacies in Nova Scotia between Oct. 1, 2010, and June 30, 2017. We performed a descriptive analysis on these events with respect to the discoverer, patient outcome, medication system stages and type. Results: We identified 131 031 events reported by community pharmacies in Nova Scotia over the study period, 98 097 of which were quality-related events. Overall, 82.0% (n = 80 488) quality-related events did not reach the patient, and 0.95% (n = 928) were associated with patient harm. Incorrect dose or frequency, incorrect quantity and incorrect drug were the most common types of quality-related events reported. Most of the quality-related events occurred at order entry, followed by preparation and dispensing, and prescribing. Interpretation: Quality-related events reported by community pharmacies differ from those reported in institutional settings with respect to patient outcome, medication system stages and type. This analysis provides valuable information to guide quality improvement initiatives to strengthen medication safety in community pharmacies.
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