Adapting Cognitive Task Analysis to Investigate Clinical Decision Making and Medication Safety Incidents.

Supplemental digital content is available in the text. Objectives: Cognitive task analysis (CTA) can yield valuable insights into healthcare professionals' cognition and inform system design to promote safe, quality care. Our objective was to adapt CTA—the critical decision method, specifically—to i...

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Publicado en:Journal of Patient Safety Vol. 15; no. 3; pp. 191 - 198
Autores principales: Russ, Alissa L., Militello, Laura G., Glassman, Peter A., Arthur, Karen J., Zillich, Alan J., Weiner, Michael
Formato: forms pictorial research tables/charts Journal Article
Publicado: Lippincott Williams & Wilkins Sep2019
Acceso en línea:Ver este registro en EBSCOhost
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      dt: Sep2019
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      pub: Lippincott Williams & Wilkins
      place: Baltimore, Maryland
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        atl: Adapting Cognitive Task Analysis to Investigate Clinical Decision Making and Medication Safety Incidents.
      aug:
        au:
          Russ, Alissa L.
          Militello, Laura G.
          Glassman, Peter A.
          Arthur, Karen J.
          Zillich, Alan J.
          Weiner, Michael
        affil: From the Center for Health Information and Communication, Department of Veterans Affairs (VA), Veterans Health Administration, Health Services Research and Development Service (CIN 13-416) and Regenstrief Institute, Inc., Indianapolis
      sug:
        subj:
          Decision Making, Clinical
          Cognition
          Task Performance and Analysis
          Patient Safety
          Quality of Health Care
          Human
          Electronic Health Records
          Adverse Drug Event
          Drug Interactions
          Descriptive Statistics
          Semi-Structured Interview
      ab: Supplemental digital content is available in the text. Objectives: Cognitive task analysis (CTA) can yield valuable insights into healthcare professionals' cognition and inform system design to promote safe, quality care. Our objective was to adapt CTA—the critical decision method, specifically—to investigate patient safety incidents, overcome barriers to implementing this method, and facilitate more widespread use of cognitive task analysis in healthcare. Methods: We adapted CTA to facilitate recruitment of healthcare professionals and developed a data collection tool to capture incidents as they occurred. We also leveraged the electronic health record (EHR) to expand data capture and used EHR-stimulated recall to aid reconstruction of safety incidents. We investigated 3 categories of medication-related incidents: adverse drug reactions, drug-drug interactions, and drug-disease interactions. Healthcare professionals submitted incidents, and a subset of incidents was selected for CTA. We analyzed several outcomes to characterize incident capture and completed CTA interviews. Results: We captured 101 incidents. Eighty incidents (79%) met eligibility criteria. We completed 60 CTA interviews, 20 for each incident category. Capturing incidents before interviews allowed us to shorten the interview duration and reduced reliance on healthcare professionals' recall. Incorporating the EHR into CTA enriched data collection. Conclusions: The adapted CTA technique was successful in capturing specific categories of safety incidents. Our approach may be especially useful for investigating safety incidents that healthcare professionals "fix and forget." Our innovations to CTA are expected to expand the application of this method in healthcare and inform a wide range of studies on clinical decision making and patient safety.
      pubtype: Academic Journal
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        pictorial
        research
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      ougenre: Article
    language: English
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