Medication errors in residential aged care facilities: A distributed cognition analysis of the information exchange process

BACKGROUND Medication safety is a pressing concern for residential aged care facilities (RACFs). Retrospective studies in RACF settings identify inadequate communication between RACFs, doctors, hospitals and community pharmacies as the major cause of medication errors. Existing literature offers limited insight about the gaps in the existing information exchange process that may lead to medication errors. The aim of this research was to explicate the cognitive distribution that underlies RACF medication ordering and delivery to identify gaps in medication-related information exchange which lead to medication errors in RACFs. METHODS The study was undertaken in three RACFs in Sydney, Australia. Data were generated through ethnographic field work over a period of five months (May-September 2011). Triangulated analysis of data primarily focused on examining the transformation and exchange of information between different media across the process. RESULTS The findings of this study highlight the extensive scope and intense nature of information exchange in RACF medication ordering and delivery. Rather than attributing error to individual care providers, the explication of distributed cognition processes enabled the identification of gaps in three information exchange dimensions which potentially contribute to the occurrence of medication errors namely: (1) design of medication charts which complicates order processing and record keeping (2) lack of coordination mechanisms between participants which results in misalignment of local practices (3) reliance on restricted communication bandwidth channels mainly telephone and fax which complicates the information processing requirements. The study demonstrates how the identification of these gaps enhances understanding of medication errors in RACFs. CONCLUSIONS Application of the theoretical lens of distributed cognition can assist in enhancing our understanding of medication errors in RACFs through identification of gaps in information exchange. Understanding the dynamics of the cognitive process can inform the design of interventions to manage errors and improve residents' safety.

[1]  Claus Bossen,et al.  Infrastructuring and Ordering Devices in Health Care: Medication Plans and Practices on a Hospital Ward , 2010, Computer Supported Cooperative Work (CSCW).

[2]  David W Bates,et al.  Research Paper: Prescribers' Responses to Alerts During Medication Ordering in the Long Term Care Setting , 2006, J. Am. Medical Informatics Assoc..

[3]  Cooper Jw Drug-related problems in nursing homes: medication errors. , 1987 .

[4]  Patrick B Ryan,et al.  Patterns in nursing home medication errors: disproportionality analysis as a novel method to identify quality improvement opportunities , 2010, Pharmacoepidemiology and drug safety.

[5]  Robert L Wears,et al.  Beyond "communication failure". , 2009, Annals of emergency medicine.

[6]  Andrew Dalley,et al.  The introduction of electronic medication charts and prescribing in aged care facilities: An evaluation , 2007 .

[7]  Joshua R. Vest,et al.  What should we measure? Conceptualizing usage in health information exchange , 2010, J. Am. Medical Informatics Assoc..

[8]  Joan S. Ash,et al.  The unintended consequences of computerized provider order entry: Findings from a mixed methods exploration , 2009, Int. J. Medical Informatics.

[9]  Edwin Hutchins,et al.  Distributed Cognition in an Airline Cockpit , 1996 .

[10]  Andrew Georgiou,et al.  Towards an understanding of the information dynamics of the handover process in aged care settings - A prerequisite for the safe and effective use of ICT , 2012, Int. J. Medical Informatics.

[11]  Edwin Hutchins How a Cockpit Remembers Its Speeds , 1995 .

[12]  D. Chou Health IT and Patient Safety: Building Safer Systems for Better Care , 2012 .

[13]  Rollin J. Fairbanks,et al.  Cognitive Artifacts in Transition: An Analysis of Information Content Changes between Manual and Electronic Patient Tracking Systems , 2008 .

[14]  James R. Carpenter,et al.  Care homes’ use of medicines study: prevalence, causes and potential harm of medication errors in care homes for older people , 2009, Quality and Safety in Health Care.

[15]  Yvonne Rogers,et al.  Distributed cognition: an alternative framework for analysing and explaining collaborative working , 1994, J. Inf. Technol..

[16]  Ann Blandford,et al.  Understanding infusion administration in the ICU through Distributed Cognition , 2012, J. Biomed. Informatics.

[17]  Marc Berg,et al.  Viewpoint Paper: Some Unintended Consequences of Information Technology in Health Care: The Nature of Patient Care Information System-related Errors , 2003, J. Am. Medical Informatics Assoc..

[18]  Lori T. Peterson,et al.  Experiences with electronic health records: Early adopters in long-term care facilities , 2011, Health care management review.

[19]  Brian Hazlehurst,et al.  Distributed cognition: An alternative model of cognition for medical informatics , 2008, Int. J. Medical Informatics.

[20]  Ann Blandford,et al.  DiCoT: A Methodology for Applying Distributed Cognition to the Design of Teamworking Systems , 2005, DSV-IS.

[21]  Linda Gavendo,et al.  The incidence of adverse drug events in two large academic long-term care facilities. , 2005, The American journal of medicine.

[22]  Abigail Sellen,et al.  The myth of the paperless office , 2001 .

[23]  Vimla L. Patel,et al.  Review: A Primer on Aspects of Cognition for Medical Informatics , 2001, J. Am. Medical Informatics Assoc..

[24]  James Shanteau,et al.  Description of Inpatient Medication Management Using Cognitive Work Analysis , 2009, Computers, informatics, nursing : CIN.

[25]  Richard J. Holden,et al.  Physicians' beliefs about using EMR and CPOE: In pursuit of a contextualized understanding of health IT use behavior , 2010, Int. J. Medical Informatics.

[26]  Alexander Turchin,et al.  An unintended consequence of electronic prescriptions: prevalence and impact of internal discrepancies , 2010, J. Am. Medical Informatics Assoc..

[27]  Charlene R. Weir,et al.  Characterizing "information transfer" by using a Joint Cognitive Systems model to improve continuity of care in the aged , 2012, Int. J. Medical Informatics.

[28]  Joanna Briggs,et al.  Strategies to reduce medication errors with reference to older adults. , 2006, Nursing standard (Royal College of Nursing (Great Britain) : 1987).

[29]  Enrico Coiera,et al.  Interdisciplinary communication: an uncharted source of medical error? , 2006, Journal of critical care.

[30]  Judy Mullan,et al.  Blister-packed medications: improving compliance and reducing adverse events , 2010 .

[31]  Robert L. Wears,et al.  Health information technology: fallacies and sober realities , 2010, J. Am. Medical Informatics Assoc..

[32]  Yan Xiao,et al.  Artifacts and collaborative work in healthcare: methodological, theoretical, and technological implications of the tangible , 2005, J. Biomed. Informatics.

[33]  Vimla L. Patel,et al.  Considering complexity in healthcare systems , 2011, J. Biomed. Informatics.

[34]  CHRISTINE A. HALVERSON,et al.  Activity Theory and Distributed Cognition: Or What Does CSCW Need to DO with Theories? , 2002, Computer Supported Cooperative Work (CSCW).

[35]  Vimla L. Patel,et al.  The Cognitive Complexity of a Provider Order Entry Interface , 2003, AMIA.

[36]  Suzanne Bakken,et al.  Model development for EHR interdisciplinary information exchange of ICU common goals , 2011, Int. J. Medical Informatics.

[37]  Nick Barber,et al.  The influence of formulation and medicine delivery system on medication administration errors in care homes for older people , 2011, Quality and Safety in Health Care.

[38]  Vimla L. Patel,et al.  Translational cognition for decision support in critical care environments: A review , 2008, J. Biomed. Informatics.

[39]  Carla Simone,et al.  Coordination mechanisms: Towards a conceptual foundation of CSCW systems design , 1996, Computer Supported Cooperative Work (CSCW).

[40]  Adam Dubrowski,et al.  Supporting evidence-based practice for nurses through information technologies. , 2010, Worldviews on evidence-based nursing.

[41]  Sameer Malhotra,et al.  Workflow modeling in critical care: Piecing together your own puzzle , 2007, J. Biomed. Informatics.

[42]  Peter Woodward,et al.  Beyond handover: supporting awareness for continuous coverage , 2010, Cognition, Technology & Work.

[43]  Donald A. Norman,et al.  Cognitive artifacts , 1991 .

[44]  James D. Hollan,et al.  Distributed cognition: toward a new foundation for human-computer interaction research , 2000, TCHI.

[45]  Brian Hazlehurst,et al.  Distributed cognition in the heart room: How situation awareness arises from coordinated communications during cardiac surgery , 2007, J. Biomed. Informatics.

[46]  Michael F. O'Connor,et al.  Discovering Healthcare Cognition: The Use of Cognitive Artifacts to Reveal Cognitive Work , 2006 .

[47]  Terry S. Field,et al.  Application of Information Technology: Costs Associated with Developing and Implementing a Computerized Clinical Decision Support System for Medication Dosing for Patients with Renal Insufficiency in the Long-term Care Setting , 2008, J. Am. Medical Informatics Assoc..

[48]  Pascale Carayon,et al.  Behind Human Error: Taming Complexity to Improve Patient Safety , 2006 .

[49]  Stephanie M. Wilson,et al.  A method for determining information flow breakdown in clinical systems , 2007, Int. J. Medical Informatics.

[50]  Kjeld Schmidt Remarks on the complexity of cooperative work , 2002 .

[51]  A. Localio,et al.  Role of computerized physician order entry systems in facilitating medication errors. , 2005 .

[52]  Yan Xiao,et al.  Emergent CSCW systems: The resolution and bandwidth of workplaces , 2007, Int. J. Medical Informatics.

[53]  Christopher Nemeth,et al.  Minding the Gaps: Creating Resilience in Health Care , 2008 .

[54]  Susan T. Marcolina,et al.  Medication Management in Long-Term Care , 2011 .

[55]  A. Strauss,et al.  Basics of Qualitative Research , 1992 .

[56]  Richard A Hansen,et al.  Repeat medication errors in nursing homes: Contributing factors and their association with patient harm. , 2010, The American journal of geriatric pharmacotherapy.

[57]  Saturnino Luz,et al.  Fieldwork for requirements: Frameworks for mobile healthcare applications , 2010, Int. J. Hum. Comput. Stud..

[58]  Kathy Eagar,et al.  Supporting work practices, improving patient flow and monitoring performance using a clinical information management system. , 2007, Australian health review : a publication of the Australian Hospital Association.

[59]  Andrew Georgiou,et al.  Complexity of Collaborative Work in Residential Aged Care Facilities: An Analysis of Information Exchange for Medication Management , 2012, 2012 45th Hawaii International Conference on System Sciences.

[60]  J. Marriott,et al.  Gaps in continuity of medication management during the transition from hospital to residential care: An observational study (MedGap Study) , 2012, Australasian journal on ageing.

[61]  S. Jeffcott,et al.  Resilience in healthcare and clinical handover , 2009, Quality & Safety in Health Care.

[62]  Gillian Symon,et al.  The coordination of work activities: Cooperation and conflict in a hospital context , 1996, Computer Supported Cooperative Work (CSCW).

[63]  Gail L. Towsley,et al.  Medication Errors in Nursing Homes:: Incidence and Reduction Strategies , 2008 .

[64]  Richard I. Cook,et al.  Using cognitive artifacts to understand distributed cognition , 2004, IEEE Trans. Syst. Man Cybern. Part A.

[65]  S. Gavi,et al.  Adverse events due to discontinuations in drug use and dose changes in patients transferred between acute and long-term care facilities. , 2004, Archives of internal medicine.

[66]  Yvonne Rogers,et al.  Distributed Cognition and Communication. , 2006 .

[67]  David W. Bates,et al.  Paperless healthcare: Progress and challenges of an IT-enabled healthcare system , 2010 .

[68]  J. Westbrook,et al.  Examining the role of information exchange in residential aged care work practices-a survey of residential aged care facilities , 2012, BMC Geriatrics.

[69]  Robert L. Wears,et al.  Underground adaptations: case studies from health care , 2011, Cognition, Technology & Work.

[70]  Stephanie M. Wilson,et al.  Cognitive Artefacts In Support Of Medical Shift Handover: An In-Use, In-Situ Evaluation , 2019 .

[71]  J. Hanlon,et al.  Epidemiology of medication-related adverse events in nursing homes. , 2006, The American journal of geriatric pharmacotherapy.

[72]  Vimla L. Patel,et al.  The nature and occurrence of registration errors in the emergency department , 2008, Int. J. Medical Informatics.

[73]  Annette Carruthers,et al.  Accuracy of packaging of dose administration aids in regional aged care facilities in the Hunter area of New South Wales , 2008, The Medical journal of Australia.

[74]  D. Woods,et al.  Gaps in the continuity of care and progress on patient safety , 2000, BMJ : British Medical Journal.

[75]  Emily S. Patterson,et al.  How Unexpected Events Produce An Escalation Of Cognitive And Coordinative Demands , 2001 .

[76]  M. Sheelagh T. Carpendale,et al.  InfoFlow Framework for Evaluating Information Flow and New Health Care Technologies , 2010, Int. J. Hum. Comput. Interact..

[77]  K. J. Vicente,et al.  Cognitive Work Analysis: Toward Safe, Productive, and Healthy Computer-Based Work , 1999 .

[78]  Elizabeth Manias,et al.  Understanding medication safety in healthcare settings: a critical review of conceptual models. , 2011, Nursing inquiry.

[79]  Vimla L. Patel,et al.  A cognitive blueprint of collaboration in context: Distributed cognition in the psychiatric emergency department , 2006, Artif. Intell. Medicine.

[80]  Jim Warren,et al.  Introduction of electronic prescribing in an aged care facility. , 2005, Australian family physician.

[81]  Rollin J. Fairbanks,et al.  Emergency Department Status Boards: A Case Study in Information Systems Transition , 2010 .