Health Services Research & Development

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2017 HSR&D/QUERI National Conference Abstract

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1065 — A Qualitative Study of Factors in Care Coordination that Contribute to Medication Errors: Cognitive Task Analysis with VA Physicians and Pharmacists

Lead/Presenter: Cherie Luckhurst, COIN - Indianapolis
All Authors: Luckhurst C (Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Indianapolis, IN) Dismore R (Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Indianapolis, IN) Authur K (Richard L. Roudebush VA Medical Center, Indianapolis, IN) Glassman P (VA Greater Los Angeles Healthcare System, Los Angeles, CA) Ifeachor A (Richard L. Roudebush VA Medical Center, Indianapolis, IN) Weiner M (Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Indianapolis, IN) Russ AL (Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Indianapolis, IN)

Objectives:
Many adverse events in hospital settings involve medication errors, some of which originate from complications with care coordination. Care coordination is the process of managing the care of a patient that occurs between two or more individuals, including physicians, nurses, pharmacists and the patients themselves. While the subject of care coordination has been investigated in general terms, care coordination as it applies to medication safety and medication errors has scant representation in the research literature. Our objective was to identify factors in care coordination that contributed to medication errors.

Methods:
We interviewed 12 physicians and 12 pharmacists from various disciplines of care using cognitive task analysis (CTA), a qualitative technique. Participants described a total of 60 incidents from a single VA Medical Center in which an adverse event or close call in medication management had occurred. We classified the incidents according to type: adverse reaction, drug-drug interaction, or drug response affecting kidney function, and randomly chose eight incidents of each type for this analysis. Interview data were reviewed using an inductive approach. Discrepancies were resolved by consensus, and coded data were managed using NVivo software.

Results:
Four major themes emerged from these interviews that reflect factors in care coordination that led to medication safety incidents. They were (1) information technology (IT) challenges or over-reliance on technology, (2) breakdowns in existing procedures, (3) confusion around roles and responsibilities, and (4) complexity in the care of patients. These themes led us to develop several methods to improve care coordination, including facilitation of real-time communication between coordinators, expansion of access to medication-related information, and enhancements to documentation mechanisms that are tied to specific medication orders.

Implications:
Through cognitive task analysis, we identified the factors that impede healthcare professionals' ability to coordinate care for medication safety. Technology, communication, clarity about roles, and clinical complexity had strong relationships to medication-safety incidents.

Impacts:
This analysis and the potential solutions derived from it can lead to changes in care coordination that improve patient safety and health outcomes.