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Health Services Research & Development

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2012 HSR&D/QUERI National Conference Abstract

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2012 National Meeting

1022 — 9 Factors that Influence Prescribers’ Response to VA Medication Safety Checks at the Point-of-Care

Russ AL, and Zillich AJ, Roudebush VAMC HSR&D Center on Implementing Evidence-Based Practice (CIEBP); McManus MS, Roudebush VAMC; Doebbeling BN, and Saleem JJ, Roudebush VAMC HSR&D CIEBP;

VA’s Computerized Patient Record System (CPRS) warns prescribers about potential medication safety issues through automated order checks, such as drug-drug interaction and drug-allergy alerts. The vast majority of order checks are ignored or overridden, and knowledge on how to design order checks to effectively aid prescribers is lacking. The objective of this study was to observe VA prescribers during their work, uncover factors that influence how they perceive and respond to order checks at the point-of-care, and identify strategies to enhance order check design.

Field observations and interviews were conducted at a major Midwestern Veterans Affairs Medical Center and included physicians, nurse practitioners, and clinical pharmacists across five outpatient primary care clinics and eight specialty clinics. Qualitative analysis was guided by a collaborative team consisting of a human factors specialist/biomedical engineer, human factors engineer, pharmacist, and nurse practitioner. Data were analyzed inductively, without a pre-determined coding scheme. The analysis team identified initial themes, derived additional themes as the study progressed, and met as a group for 27.5 hours across 30 meetings to reach consensus on final themes.

Altogether, 320 order checks were observed across 30 prescribers and their interactions with 146 patients. The research team uncovered 44 emergent themes that influence how prescribers perceive and respond to order checks. Themes were further abstracted into nine overarching factors: order check system logic, order check redundancy, order check content, order check display, cognitive factors, pharmaceutical knowledge, medication management, workflow, and order check system reliability. Factors were organized into a framework that describes prescribers’ interactions with order checks.

Results yielded a novel framework for understanding prescribers’ response to order checks at the point-of-care. Findings from this collaborative study may be used to enhance CPRS order check design, which may ultimately reduce harm to Veterans.

VA’s order check system is used by hundreds of prescribers across the U.S. However, to our knowledge, this is the first investigation to directly observe prescribers’ interactions with order checks at the point-of-care. Study results can inform order check redesigns to improve the quality, efficiency, and safety of VA prescribing.

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