international journal of medical informatics 76S ( 2 0 0 7 ) S48–S57 journal homepage: www.intl.elsevierhealth.com/journals/ijmi Who is in charge of patient safety? Work practice, work processes and utopian views of automatic drug dispensing systems Ellen Balka a,b,* , Nicki Kahnamoui a,c , Kelsey Nutland a a School of Communication and Assessment of Technology in Context Design Laboratory, Simon Fraser University, Burnaby, BC, Canada b Centre for Clinical Epidemiology & Evaluation, Vancouver Coastal Health Research Institute, 710-828 W. 10th Ave., Vancouver, V5Z 1L8 BC, Canada c Interdisciplinary Studies, Simon Fraser University, Burnaby, BC, Canada article info Article history: Received 9 March 2006 Accepted 11 May 2006 Keywords: Automation Computer hardware Computer systems Medication systems Hospital Technology assessment Unit dose distribution systems abstract In June 2003, a large, Canadian tertiary care facility introduced automatic drug dispens- ing machines on all units when it opened up a new building. In this paper, we provide an overview of the automatic drug dispensing system (ADS) implementation at the hospital. Our findings, based on daily field observations and interviews during and after implemen- tation, with regular follow-up visits to the field site illustrate how the introduction of the ADS brought to light work practices that sometimes compromised patient safety. We suggest that utopian views of automatic drug dispensing machines obfuscate the chal- lenges inherent to implementing such systems, and deter stakeholders from performing rigorous evaluation of the costs (both social and economic) and benefits of investing in such systems. Our work contributes to debates about the socio-technical efficacy of automat- ing medication dispensing and delivery, and suggests that the balance of power in the patient safety equation lies in the work context and implementation issues, and not just the technology. For technology implementations to be successful considering that technologies frequently cross over jurisdictional boundaries, planning and implementation have to be conducted at a system wide level. © 2006 Published by Elsevier Ireland Ltd. 1. Introduction and background In June 2003, a large, Canadian tertiary care facility intro- duced automatic drug dispensing machines on all units when it opened up a new building. In this paper, we provide an overview of the automatic drug dispensing system (ADS) implementation at the hospital, and discuss some of the issues that arose during the implementation of the ADS. Our findings are based on daily field observations and interviews that occurred during and after the implementation, for a 2- * Corresponding author at: Tel.: +1 604 875 5219. E-mail address: ellenb@sfu.ca (E. Balka). month period, with regular follow-up visits to the field site over the 16 months following implementation. The ADS is a tightly controlled system for dispensing med- ications, and it is intended to replace medicine carts that were previously used by staff for unit based storage of medications. It is an automated cabinet made up of a touch screen monitor and keyboard, with various other secure storage spaces con- nected to it (i.e. refrigerator). To access these storage spaces a user id and password is required, which is issued to staff with access rights (i.e. nurses). According to a pharmacist on 1386-5056/$ – see front matter © 2006 Published by Elsevier Ireland Ltd. doi:10.1016/j.ijmedinf.2006.05.038