Int J Med Inform - Medication errors in residential aged care facilities: a distributed cognition analysis of the information exchange process.

Tópicos

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Resumo

CKGROUND: 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.

Resumo Limpo

ckground medic safeti press concern residenti age care facil racf retrospect studi racf set identifi inadequ communic racf doctor hospit communiti pharmaci major caus medic error exist literatur offer limit insight gap exist inform exchang process may lead medic error aim research explic cognit distribut under racf medic order deliveri identifi gap medicationrel inform exchang lead medic error racfsmethod studi undertaken three racf sydney australia data generat ethnograph field work period five month mayseptemb triangul analysi data primarili focus examin transform exchang inform differ media across processresult find studi highlight extens scope intens natur inform exchang racf medic order deliveri rather attribut error individu care provid explic distribut cognit process enabl identif gap three inform exchang dimens potenti contribut occurr medic error name design medic chart complic order process record keep lack coordin mechan particip result misalign local practic relianc restrict communic bandwidth channel main telephon fax complic inform process requir studi demonstr identif gap enhanc understand medic error racfsconclus applic theoret len distribut cognit can assist enhanc understand medic error racf identif gap inform exchang understand dynam cognit process can inform design intervent manag error improv resid safeti

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