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Russ-Jara AL, Elkhadragy N, Arthur KJ, DiIulio JB, Militello LG, Ifeachor AP, Glassman PA, Zillich AJ, Weiner M. Cognitive task analysis of clinicians' drug-drug interaction management during patient care and implications for alert design. BMJ Open 2023; 13:e075512. [PMID: 38040422 PMCID: PMC10693887 DOI: 10.1136/bmjopen-2023-075512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 10/09/2023] [Indexed: 12/03/2023] Open
Abstract
BACKGROUND Drug-drug interactions (DDIs) are common and can result in patient harm. Electronic health records warn clinicians about DDIs via alerts, but the clinical decision support they provide is inadequate. Little is known about clinicians' real-world DDI decision-making process to inform more effective alerts. OBJECTIVE Apply cognitive task analysis techniques to determine informational cues used by clinicians to manage DDIs and identify opportunities to improve alerts. DESIGN Clinicians submitted incident forms involving DDIs, which were eligible for inclusion if there was potential for serious patient harm. For selected incidents, we met with the clinician for a 60 min interview. Each interview transcript was analysed to identify decision requirements and delineate clinicians' decision-making process. We then performed an inductive, qualitative analysis across incidents. SETTING Inpatient and outpatient care at a major, tertiary Veterans Affairs medical centre. PARTICIPANTS Physicians, pharmacists and nurse practitioners. OUTCOMES Themes to identify informational cues that clinicians used to manage DDIs. RESULTS We conducted qualitative analyses of 20 incidents. Data informed a descriptive model of clinicians' decision-making process, consisting of four main steps: (1) detect a potential DDI; (2) DDI problem-solving, sensemaking and planning; (3) prescribing decision and (4) resolving actions. Within steps (1) and (2), we identified 19 information cues that clinicians used to manage DDIs for patients. These cues informed their subsequent decisions in steps (3) and (4). Our findings inform DDI alert recommendations to improve clinicians' decision-making efficiency, confidence and effectiveness. CONCLUSIONS Our study provides three key contributions. Our study is the first to present an illustrative model of clinicians' real-world decision making for managing DDIs. Second, our findings add to scientific knowledge by identifying 19 cognitive cues that clinicians rely on for DDI management in clinical practice. Third, our results provide essential, foundational knowledge to inform more robust DDI clinical decision support in the future.
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Affiliation(s)
- Alissa L Russ-Jara
- Health Services Research and Development Service CIN 13-416, Center for Health Information and Communication, U.S. Department of Veterans Affairs (VA), Veterans Health Administration, Indianapolis, Indiana, USA
- Department of Pharmacy Practice, College of Pharmacy, Purdue University, West Lafayette, Indiana, USA
- Regenstrief Center for Healthcare Engineering, Purdue University, West Lafayette, Indiana, USA
| | - Nervana Elkhadragy
- Department of Pharmacy Practice, College of Pharmacy, Purdue University, West Lafayette, Indiana, USA
- School of Pharmacy, University of Wyoming, Laramie, Wyoming, USA
| | - Karen J Arthur
- Richard L. Roudebush VA Medical Center, U.S. Department of Veterans Affairs, Veterans Health Administration, Indianapolis, Indiana, USA
| | | | | | - Amanda P Ifeachor
- Richard L. Roudebush VA Medical Center, U.S. Department of Veterans Affairs, Veterans Health Administration, Indianapolis, Indiana, USA
| | - Peter A Glassman
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
- Pharmacy Benefits Management Services, Department of Veterans Affairs (VA), Washington, DC, USA
- Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Alan J Zillich
- Department of Pharmacy Practice, College of Pharmacy, Purdue University, West Lafayette, Indiana, USA
| | - Michael Weiner
- Health Services Research and Development Service CIN 13-416, Center for Health Information and Communication, U.S. Department of Veterans Affairs (VA), Veterans Health Administration, Indianapolis, Indiana, USA
- Richard L. Roudebush VA Medical Center, U.S. Department of Veterans Affairs, Veterans Health Administration, Indianapolis, Indiana, USA
- Center for Health Services Research, Regenstrief Institute, Inc, Indianapolis, Indiana, USA
- Department of Medicine, Indiana University, Indianapolis, Indiana, USA
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Hughes AM, Riska K, Farmer MJS, Krishnakumar D, Shea CM, Hess DR, Lindenauer PK, Stefan MS. Analysis of shared cognitive tasks in the application of non-invasive ventilation to patients with COPD exacerbation. J Interprof Care 2023; 37:576-587. [PMID: 36264072 PMCID: PMC10983066 DOI: 10.1080/13561820.2022.2118681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 08/22/2022] [Accepted: 08/22/2022] [Indexed: 12/24/2022]
Abstract
Interprofessional teamwork plays a key role in the uptake of evidence-based interventions, such as noninvasive ventilation (NIV) for patients with exacerbated Chronic Obstructive Pulmonary Disease (COPD). We aimed to identify the shared cognitive tasks in interprofessional teams using NIV for patients with COPD exacerbation. We used a cognitive task analysis approach (CTA) to engage nurses, rapid response team members, respiratory therapists, and physicians involved in the use of NIV to treat patients with COPD exacerbation. Clinicians participated in a semi-structured interview (n = 21) that elicited cognitions needed to treat COPD exacerbation. Three shared cognitive tasks were identified: Complete a thorough assessment, Formulate a care plan, and Continuously monitor patient status. Findings attest to the importance of having access to up-to-date information and expertise necessary to make accurate clinical inferences for patient assessment. Shared understanding of the formulated care plan among all members of the care team was important to its execution. Continuous monitoring was crucial; however, this cognitive task relied on patient assessment skills and ongoing collaboration within the clinical care team. Application of NIV for patients with COPD exacerbation may require enhancing collaboration through nontechnical skills and interprofessional training.
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Affiliation(s)
- Ashley M Hughes
- Department of Biomedical and Health Information Sciences, University of Illinois at Chicago, Chicago
- Center for Innovations in Chronic, Complex Healthcare, Edward Hines JR VA Medical Center, Hines
| | - Karen Riska
- Department of Healthcare Delivery and Population Sciences, University of Massachusetts Chan Medical School - Baystate, Springfield
| | - Mary Jo S Farmer
- Department of Medicine, University of Massachusetts Chan Medical School - Baystate, Springfield
- Division of Pulmonary and Critical Care, Department of Medicine, University of Massachusetts Chan Medical School - Baystate, Springfield
| | | | - Christopher M Shea
- Department of Health Policy and Management, Gilling's School of Global Public Health, University of North Carolina-Chapel Hill, Chapel Hill, NC, United States
| | - Dean R Hess
- College of Professional Studies, Respiratory Care Leadership, Northeastern University, Boston MS, United States
- Department of Respiratory Care, Massachusetts General Hospital, Boston, MS, United States
| | - Peter K Lindenauer
- Department of Healthcare Delivery and Population Sciences, University of Massachusetts Chan Medical School - Baystate, Springfield
- Department of Medicine, University of Massachusetts Chan Medical School - Baystate, Springfield
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MS, United States
| | - Mihaela S Stefan
- Department of Healthcare Delivery and Population Sciences, University of Massachusetts Chan Medical School - Baystate, Springfield
- Department of Medicine, University of Massachusetts Chan Medical School - Baystate, Springfield
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Flory JH, Guelce D, Goytia C, Li J, Min JY, Mushlin A, Orloff J, Mayer V. Prescriber Uncertainty as Opportunity to Improve Care of Type 2 Diabetes with Chronic Kidney Disease: Mixed Methods Study. J Gen Intern Med 2023; 38:1476-1483. [PMID: 36316625 PMCID: PMC10160326 DOI: 10.1007/s11606-022-07838-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 10/05/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND Over 5 million patients in the United States have type 2 diabetes mellitus (T2D) with chronic kidney disease (CKD); antidiabetic drug selection for this population is complex and has important implications for outcomes. OBJECTIVE To better understand how providers choose antidiabetic drugs in T2D with CKD DESIGN: Mixed methods. Interviews with providers underwent qualitative analysis using grounded theory to identify themes related to antidiabetic drug prescribing. A provider survey used vignettes and direct questions to quantitatively assess prescribers' knowledge and preferences. A retrospective cohort analysis of real-world prescribing data assessed the external validity of the interview and survey findings. PARTICIPANTS Primary care physicians, endocrinologists, nurse-practitioners, and physicians' assistants were eligible for interviews; primary care physicians and endocrinologists were eligible for the survey; prescribing data were derived from adult patients with serum creatinine data. MAIN MEASURES Interviews were qualitative; for the survey and retrospective cohort, proportion of patients receiving metformin was the primary outcome. KEY RESULTS Interviews with 9 providers identified a theme of uncertainty about guidelines for prescribing antidiabetic drugs in patients with T2D and CKD. The survey had 105 respondents: 74 primary care providers and 31 endocrinologists. Metformin was the most common choice for patients with T2D and CKD. Compared to primary care providers, endocrinologists were less likely to prescribe metformin at levels of kidney function at which it is contraindicated and more likely to correctly answer a question about metformin's contraindications (71% versus 41%) (p < .05). Real-world data were consistent with survey findings, and further showed low rates of use of sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide 1 receptor agonists (<10%) in patients with eGFR below 60 ml/min/1.73m2. CONCLUSIONS Providers are unsure how to treat T2D with CKD and incompletely informed as to existing guidelines. This suggests opportunities to improve care.
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Affiliation(s)
- James H Flory
- Endocrinology Service, Department of Subspecialty Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Dominique Guelce
- Department of Population Health Sciences, Weill Cornell Medical College, New York, NY, USA
| | | | - Jing Li
- Department of Population Health Sciences, Weill Cornell Medical College, New York, NY, USA
| | - Jea Young Min
- Department of Population Health Sciences, Weill Cornell Medical College, New York, NY, USA
| | - Al Mushlin
- Department of Population Health Sciences, Weill Cornell Medical College, New York, NY, USA
| | - Jeremy Orloff
- Department of Population Health Sciences, Weill Cornell Medical College, New York, NY, USA
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Schütze A, Benöhr P, Haubitz M, Radziwill R, Hohmann C. Development of a list with renally relevant drugs as a tool to increase medicines optimisation in patients with chronic kidney disease. Eur J Hosp Pharm 2023; 30:46-52. [PMID: 33986026 PMCID: PMC9811534 DOI: 10.1136/ejhpharm-2020-002571] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 04/12/2021] [Accepted: 04/27/2021] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVES Chronic kidney disease (CKD) is a common disorder all over the world. Therapeutic goals are early detection of declining renal function and implementation of adequate pharmacological treatments regarding underlying and secondary diseases. As therapy becomes more complex with increasing stages of CKD, a decision-making tool for healthcare professionals could help to ensure safe drug treatment in patients with CKD in the outpatient setting. Therefore, a list of renally relevant drugs as a decision-making tool was developed to improve medicines optimisation for CKD patients in the outpatient setting long term. METHODS A renally relevant drug list (RRD-list) with renally relevant drugs, based on data from a study on medicines optimisation in patients with CKD from June 2015 to March 2018, was developed at the nephrological outpatient clinic at the Klinikum Fulda, Germany. The whole study is published elsewhere. A clinical pharmacist reviewed the patients' medications, current drug-related problems and all nephrologists' recommendations, and categorised all detected drugs into renally relevant and non-renally relevant groups. The 10 most frequently detected renally relevant drug groups were summarised in the RRD-list and extended by treatment alternatives and advice. RESULTS The medication of 160 patients, who were receiving overall 1376 drugs, was analysed; 831 drugs were defined as renally relevant. Drug-related problems were caused by 543 renally relevant drugs. The nephrologists made 292 recommendations regarding 28 drug classes. Considering the 10 most frequent drug groups, in total 16 renally relevant drug groups with 36 drug classes were added to the RRD-list. CONCLUSIONS The RRD-list could be an essential tool for all healthcare professionals in their daily work, such as general practitioners and community pharmacists, for the treatment of patients with renal insufficiency.
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Affiliation(s)
- Alexander Schütze
- Department of Pharmacy, Klinikum Fulda gAG, Fulda, Germany
- Faculty of Pharmacy, University of Marburg Institute of Pharmacology and Clinical Pharmacy, Marburg, Germany
| | - Peter Benöhr
- Department of Nephrology, Klinikum Fulda gAG, Fulda, Germany
| | - Marion Haubitz
- Department of Nephrology, Klinikum Fulda gAG, Fulda, Germany
| | | | - Carina Hohmann
- Department of Pharmacy, Klinikum Fulda gAG, Fulda, Germany
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5
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Martini N, Choong JW, Dela Cruz PD, Lau H, Lim H, Liu R, Lim AG, Marshall D. Assessing antibiotic prescribing in nurse practitioners: Applied cognitive task analysis. INTERNATIONAL JOURNAL OF NURSING STUDIES ADVANCES 2022; 4:100101. [PMID: 38745626 PMCID: PMC11080434 DOI: 10.1016/j.ijnsa.2022.100101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 09/12/2022] [Accepted: 09/23/2022] [Indexed: 10/14/2022] Open
Abstract
Background Prescribing antibiotics is a demanding and complex task where decision-making skills are of critical importance to minimize the risk of antimicrobial resistance. Despite its importance, little is known about the decision-making skills and cognitive strategies new Nurse Practitioners (NPs) use when prescribing antibiotics. Objective To identify the cognitive demands of antibiotic prescribing complexity and to explore the cognitive strategies that new NPs in New Zealand use when prescribing antibiotics. Design A qualitative approach using Applied Cognitive Task Analysis (ACTA) methodology. Participants A purposive sample was recruited consisting of five NPs who had been registered within the last five years and were prescribing antibiotics as part of their scope of practice. Methods In-depth face-to-face interviews consisting of a task diagram interview and a knowledge audit were conducted and analyzed following the ACTA protocol. Results Four cognitive elements were identified from the data which showed the cognitive demands of prescribing antibiotics, and the cues and strategies NPs use for safe practice. These were: 1 prescribing in the face of uncertainty (complex patients and diagnostic uncertainty); 2 making clinical decisions with insufficient/poor guidance (lack of guidelines, conflicting information); 3 producing an individualized treatment plan in view of clinical and non-clinical patient factors (patient demand/expectation, inadequate patient education, risks versus benefits of antibiotic treatment); 4 ensuring treatment efficacy and continuity of care (ineffective treatment, patient care follow up). Conclusion The ACTA framework has given insight into the current antibiotic prescribing practice of new NPs, identifying areas where professional development courses and treatment resources can be targeted to support antibiotic prescribing. NPs are likely to benefit from resources that are freely available and reflect national or local antimicrobial data. Further work is also warranted to determine whether targeted education resources and clinical pathways will help with diagnostic uncertainty, and how this could be embedded into existing curricula.
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Affiliation(s)
- Nataly Martini
- School of Pharmacy, Faculty of Medical and Health Sciences, The University of Auckland, Private Bag 92019, Auckland 1142, New Zealand
| | - Je Wei Choong
- School of Pharmacy, Faculty of Medical and Health Sciences, The University of Auckland, Private Bag 92019, Auckland 1142, New Zealand
| | - Paula Donamae Dela Cruz
- School of Pharmacy, Faculty of Medical and Health Sciences, The University of Auckland, Private Bag 92019, Auckland 1142, New Zealand
| | - Helen Lau
- School of Pharmacy, Faculty of Medical and Health Sciences, The University of Auckland, Private Bag 92019, Auckland 1142, New Zealand
| | - Hanna Lim
- School of Pharmacy, Faculty of Medical and Health Sciences, The University of Auckland, Private Bag 92019, Auckland 1142, New Zealand
| | - Roger Liu
- School of Pharmacy, Faculty of Medical and Health Sciences, The University of Auckland, Private Bag 92019, Auckland 1142, New Zealand
| | - Anecita Gigi Lim
- School of Nursing, Faculty of Medical and Health Sciences, School of Pharmacy, The University of Auckland, Private Bag 92019, Auckland 1142, New Zealand
| | - Dianne Marshall
- School of Nursing, Faculty of Medical and Health Sciences, School of Pharmacy, The University of Auckland, Private Bag 92019, Auckland 1142, New Zealand
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6
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Nguyen KA, Militello LG, Ifeachor A, Arthur KJ, Glassman PA, Zillich AJ, Weiner M, Russ-Jara AL. Strategies prescribers and pharmacists use to identify and mitigate adverse drug reactions in inpatient and outpatient care: a cognitive task analysis at a US Veterans Affairs Medical Center. BMJ Open 2022; 12:e052401. [PMID: 35190423 PMCID: PMC8862429 DOI: 10.1136/bmjopen-2021-052401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To develop a descriptive model of the cognitive processes used to identify and resolve adverse drug reactions (ADRs) from the perspective of healthcare providers in order to inform future informatics efforts SETTING: Inpatient and outpatient care at a tertiary care US Veterans Affairs Medical Center. PARTICIPANTS Physicians, nurse practitioners and pharmacists who report ADRs. OUTCOMES Descriptive model and emerging themes from interviews. RESULTS We conducted critical decision method interviews with 10 physicians and 10 pharmacists. No nurse practitioners submitted ADR incidents. We generated a descriptive model of an ADR decision-making process and analysed emerging themes, categorised into four stages: detection of potential ADR, investigation of the problem's cause, risk/benefit consideration, and plan, action and follow-up. Healthcare professionals (HCPs) relied on several confirmatory or disconfirmatory cues to detect and investigate potential ADRs. Evaluating risks and benefits of related medications played an essential role in HCPs' pursuits of solutions CONCLUSIONS: This study provides an illustrative model of how HCPs detect problems and make decisions regarding ADRs. The design of supporting technology for potential ADR problems should align with HCPs' real-world cognitive strategies, to assist fully in detecting and preventing ADRs for patients.
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Affiliation(s)
- Khoa Anh Nguyen
- Center for Health Information and Communication, Richard L Roudebush VA Medical Center, Indianapolis, Indiana, USA
- Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, Florida, USA
| | | | - Amanda Ifeachor
- Richard L Roudebush VA Medical Center, Indianapolis, Indiana, USA
| | - Karen J Arthur
- VA Health Services Research and Development Center on Implementing Evidence-Based Practice, Roudebush VA Medical Center, Indianapolis, Indiana, USA
| | - Peter A Glassman
- Pharmacy Benefits Management Services, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Alan J Zillich
- Department of Pharmacy Practice, Purdue University, College of Pharmacy, West Lafayette, Indiana, USA
| | - Michael Weiner
- Center for Health Information and Communication, Richard L Roudebush VA Medical Center, Indianapolis, Indiana, USA
- Regenstrief Institute Inc, Indianapolis, Indiana, USA
| | - Alissa L Russ-Jara
- Center for Health Information and Communication, Richard L Roudebush VA Medical Center, Indianapolis, Indiana, USA
- Department of Pharmacy Practice, Purdue University, College of Pharmacy, West Lafayette, Indiana, USA
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7
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Holden RJ, Abebe E, Russ-Jara AL, Chui MA. Human factors and ergonomics methods for pharmacy research and clinical practice. Res Social Adm Pharm 2021; 17:2019-2027. [PMID: 33985892 PMCID: PMC8603214 DOI: 10.1016/j.sapharm.2021.04.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 04/28/2021] [Accepted: 04/29/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Human factors and ergonomics (HFE) is a scientific and practical human-centered discipline that studies and improves human performance in sociotechnical systems. HFE in pharmacy promotes the human-centered design of systems to support individuals and teams performing medication-related work. OBJECTIVE To review select HFE methods well suited to address pharmacy challenges, with examples of their application in pharmacy. METHODS We define the scope of HFE methods in pharmacy as applications to pharmacy settings, such as inpatient or community pharmacies, as well as medication-related phenomena such as medication safety, adherence, or deprescribing. We identify and present seven categories of HFE methods suited to widespread use for pharmacy research and clinical practice. RESULTS Categories of HFE methods applicable to pharmacy include work system analysis; task analysis; workload assessment; medication safety and error analysis; user-centered and participatory design; usability evaluation; and physical ergonomics. HFE methods are used in three broad phases of human-centered design and evaluation: study; design; and evaluation. The most robust applications of HFE methods involve the combination of HFE methods across all three phases. Two cases illustrate such a comprehensive application of HFE: one case of medication package, label, and information design and a second case of human-centered design of a digital decision aid for medication safety. CONCLUSIONS Pharmacy, including the places where pharmacy professionals work and the multistep process of medication use across people and settings, can benefit from HFE. This is because pharmacy is a human-centered sociotechnical system with an existing tradition of studying and analyzing the present state, designing solutions to problems, and evaluating those solutions in laboratory or practice settings. We conclude by addressing common concerns about the implementation of HFE methods and urge the adoption of HFE methods in pharmacy.
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Affiliation(s)
- Richard J Holden
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA; Center for Aging Research, Regenstrief Institute, Indianapolis, IN, USA; Center for Health Innovation and Implementation Science, Indiana Clinical and Translational Sciences Institute, Indianapolis, IN, USA.
| | - Ephrem Abebe
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA; Department of Pharmacy Practice, College of Pharmacy, Purdue University, West Lafayette, IN, USA
| | - Alissa L Russ-Jara
- Department of Pharmacy Practice, College of Pharmacy, Purdue University, West Lafayette, IN, USA
| | - Michelle A Chui
- Social & Administrative Sciences, School of Pharmacy, University of Wisconsin-Madison, Madison, WI, USA
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8
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Russ-Jara AL, Luckhurst CL, Dismore RA, Arthur KJ, Ifeachor AP, Militello LG, Glassman PA, Zillich AJ, Weiner M. Care Coordination Strategies and Barriers during Medication Safety Incidents: a Qualitative, Cognitive Task Analysis. J Gen Intern Med 2021; 36:2212-2220. [PMID: 33479924 PMCID: PMC8342616 DOI: 10.1007/s11606-020-06386-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 12/02/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Medication errors are prevalent in healthcare institutions worldwide, often arising from difficulties in care coordination among primary care providers, specialists, and pharmacists. Greater knowledge about care coordination surrounding medication safety incidents can inform efforts to improve patient safety. OBJECTIVES To identify strategies that hospital and outpatient healthcare professionals (HCPs) use, and barriers encountered, when they coordinate care during a medication safety incident involving an adverse drug reaction, drug-drug interaction, or drug-renal concern. DESIGN We asked HCPs to complete a form whenever they encountered these incidents and intervened to prevent or mitigate patient harm. We stratified incidents across HCP roles and incident categories to conduct follow-up cognitive task analysis interviews with HCPs. PARTICIPANTS We invited all physicians and pharmacists working in inpatient or outpatient care at a tertiary Veterans Affairs Medical Center. We examined 24 incidents: 12 from physicians and 12 from pharmacists, with a total of 8 incidents per category. APPROACH Interviews were transcribed and analyzed via a two-stage inductive, qualitative analysis. In stage 1, we analyzed each incident to identify decision requirements. In stage 2, we analyzed results across incidents to identify emergent themes. KEY RESULTS Most incidents (19, 79%) were from outpatient care. HCPs relied on four main strategies to coordinate care: cognitive decentering; collaborative decision-making; back-up behaviors; and contingency planning. HCPs encountered four main barriers: role ambiguity and constraints, breakdowns (e.g., delays) in care, challenges related to the electronic health record, and factors that increased coordination complexity. Each strategy and barrier occurred across all incident categories and HCP groups. Pharmacists went to extra effort to ensure safety plans were implemented. CONCLUSIONS Similar strategies and barriers were evident across HCP groups and incident types. Strategies for enhancing patient safety may be strengthened by deliberate organizational support. Some barriers could be addressed by improving work systems.
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Affiliation(s)
- Alissa L Russ-Jara
- Center for Health Information and Communication, U.S. Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service CIN 13-416, Indianapolis, IN, USA. .,Department of Pharmacy Practice, College of Pharmacy, Purdue University, West Lafayette, IN, USA. .,Regenstrief Institute, Inc., Indianapolis, IN, USA.
| | - Cherie L Luckhurst
- Center for Health Information and Communication, U.S. Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service CIN 13-416, Indianapolis, IN, USA
| | - Rachel A Dismore
- Center for Health Information and Communication, U.S. Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service CIN 13-416, Indianapolis, IN, USA
| | - Karen J Arthur
- Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, IN, USA
| | - Amanda P Ifeachor
- Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, IN, USA
| | | | - Peter A Glassman
- Pharmacy Benefits Management Services, Department of Veterans Affairs, Washington DC, USA.,David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Alan J Zillich
- Department of Pharmacy Practice, College of Pharmacy, Purdue University, West Lafayette, IN, USA
| | - Michael Weiner
- Center for Health Information and Communication, U.S. Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service CIN 13-416, Indianapolis, IN, USA.,Regenstrief Institute, Inc., Indianapolis, IN, USA.,Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, IN, USA.,Indiana University Center for Health Services and Outcomes Research, Indianapolis, IN, USA
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9
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Hong JC, Hauser ER, Redding TS, Sims KJ, Gellad ZF, O'Leary MC, Hyslop T, Madison AN, Qin X, Weiss D, Bullard AJ, Williams CD, Sullivan BA, Lieberman D, Provenzale D. Characterizing chronological accumulation of comorbidities in healthy veterans: a computational approach. Sci Rep 2021; 11:8104. [PMID: 33854078 PMCID: PMC8046765 DOI: 10.1038/s41598-021-85546-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 12/14/2020] [Indexed: 12/13/2022] Open
Abstract
Understanding patient accumulation of comorbidities can facilitate healthcare strategy and personalized preventative care. We applied a directed network graph to electronic health record (EHR) data and characterized comorbidities in a cohort of healthy veterans undergoing screening colonoscopy. The Veterans Affairs Cooperative Studies Program #380 was a prospective longitudinal study of screening and surveillance colonoscopy. We identified initial instances of three-digit ICD-9 diagnoses for participants with at least 5 years of linked EHR history (October 1999 to December 2015). For diagnoses affecting at least 10% of patients, we calculated pairwise chronological relative risk (RR). iGraph was used to produce directed graphs of comorbidities with RR > 1, as well as summary statistics, key diseases, and communities. A directed graph based on 2210 patients visualized longitudinal development of comorbidities. Top hub (preceding) diseases included ischemic heart disease, inflammatory and toxic neuropathy, and diabetes. Top authority (subsequent) diagnoses were acute kidney failure and hypertensive chronic kidney failure. Four communities of correlated comorbidities were identified. Close analysis of top hub and authority diagnoses demonstrated known relationships, correlated sequelae, and novel hypotheses. Directed network graphs portray chronologic comorbidity relationships. We identified relationships between comorbid diagnoses in this aging veteran cohort. This may direct healthcare prioritization and personalized care.
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Affiliation(s)
- Julian C Hong
- Cooperative Studies Program Epidemiology Center-Durham, Durham VA Health Care System, Durham, NC, USA. .,Department of Radiation Oncology, University of California, San Francisco, San Francisco, CA, USA. .,Bakar Computational Health Sciences Institute, University of California, San Francisco, San Francisco, CA, USA.
| | - Elizabeth R Hauser
- Cooperative Studies Program Epidemiology Center-Durham, Durham VA Health Care System, Durham, NC, USA.,Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Thomas S Redding
- Cooperative Studies Program Epidemiology Center-Durham, Durham VA Health Care System, Durham, NC, USA
| | - Kellie J Sims
- Cooperative Studies Program Epidemiology Center-Durham, Durham VA Health Care System, Durham, NC, USA
| | - Ziad F Gellad
- Cooperative Studies Program Epidemiology Center-Durham, Durham VA Health Care System, Durham, NC, USA.,Department of Medicine, Duke University, Durham, NC, USA
| | - Meghan C O'Leary
- Cooperative Studies Program Epidemiology Center-Durham, Durham VA Health Care System, Durham, NC, USA
| | - Terry Hyslop
- Cooperative Studies Program Epidemiology Center-Durham, Durham VA Health Care System, Durham, NC, USA.,Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Ashton N Madison
- Cooperative Studies Program Epidemiology Center-Durham, Durham VA Health Care System, Durham, NC, USA
| | - Xuejun Qin
- Cooperative Studies Program Epidemiology Center-Durham, Durham VA Health Care System, Durham, NC, USA.,Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - David Weiss
- Cooperative Studies Program Coordinating Center, Perry Point VA Medical Center, Perry Point, MD, USA
| | - A Jasmine Bullard
- Cooperative Studies Program Epidemiology Center-Durham, Durham VA Health Care System, Durham, NC, USA
| | - Christina D Williams
- Cooperative Studies Program Epidemiology Center-Durham, Durham VA Health Care System, Durham, NC, USA.,Department of Medicine, Duke University, Durham, NC, USA
| | - Brian A Sullivan
- Cooperative Studies Program Epidemiology Center-Durham, Durham VA Health Care System, Durham, NC, USA.,Department of Medicine, Duke University, Durham, NC, USA
| | - David Lieberman
- VA Portland Health Care System, Portland, OR, USA.,Oregon Health and Science University, Portland, OR, USA
| | - Dawn Provenzale
- Cooperative Studies Program Epidemiology Center-Durham, Durham VA Health Care System, Durham, NC, USA. .,Department of Medicine, Duke University, Durham, NC, USA.
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Koufidis C, Manninen K, Nieminen J, Wohlin M, Silén C. Unravelling the polyphony in clinical reasoning research in medical education. J Eval Clin Pract 2021; 27:438-450. [PMID: 32573080 DOI: 10.1111/jep.13432] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 05/19/2020] [Accepted: 05/27/2020] [Indexed: 11/27/2022]
Abstract
RATIONALE Clinical reasoning lies at the heart of medical practice and has a long research tradition. Nevertheless, research is scattered across diverse academic disciplines with different research traditions in a wide range of scientific journals. This polyphony is a source of conceptual confusion. AIMS AND OBJECTIVES We sought to explore the underlying theoretical assumptions of clinical reasoning aiming to promote a comprehensive conceptual and theoretical understanding of the subject area. In particular, we asked how clinical reasoning is defined and researched and what conceptualizations are relevant to such uses. METHODS A scoping review of the clinical reasoning literature was undertaken. Using a "snowball" search strategy, the wider scientific literature on clinical reasoning was reviewed in order to clarify the different underlying conceptual assumptions underlying research in clinical reasoning, particularly to the field of medical education. This literature included both medical education, as well as reasoning research in other academic disciplines outside medical education, that is relevant to clinical reasoning. A total of 124 publications were included in the review. RESULTS A detailed account of the research traditions in clinical reasoning research is presented. In reviewing this research, we identified three main conceptualisations of clinical reasoning: "reasoning as cognitive activity," "reasoning as contextually situated activity," and "reasoning as socially mediated activity." These conceptualisations reflected different theoretical understandings of clinical reasoning. Each conceptualisation was defined by its own set of epistemological assumptions, which we have identified and described. CONCLUSIONS Our work seeks to bring into awareness implicit assumptions of the ongoing clinical reasoning research and to hopefully open much needed channels of communication between the different research communities involved in clinical reasoning research in the field.
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Affiliation(s)
- Charilaos Koufidis
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden.,Centre for Research and Development, Uppsala University/Region Gävleborg, Gävle, Sweden
| | - Katri Manninen
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden.,Department of Infectious Diseases, Karolinska University Hospital, Huddinge, Sweden
| | - Juha Nieminen
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
| | - Martin Wohlin
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Charlotte Silén
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
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