Medication errors in residential aged care facilities: A distributed cognition analysis of the information exchange process

Tariq, Amina, Georgiou, Andrew, & Westbrook, Johanna (2013) Medication errors in residential aged care facilities: A distributed cognition analysis of the information exchange process. International Journal of Medical Informatics, 82(5), pp. 299-312.

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Abstract

Background

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.

Impact and interest:

12 citations in Scopus
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6 citations in Web of Science®

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ID Code: 93936
Item Type: Journal Article
Refereed: Yes
Keywords: Aged care, Community pharmacy, Distributed cognition, Information exchange, Medication ordering
DOI: 10.1016/j.ijmedinf.2012.08.006
ISSN: 1386-5056
Divisions: Current > QUT Faculties and Divisions > Faculty of Health
Current > Institutes > Institute of Health and Biomedical Innovation
Current > Schools > School of Public Health & Social Work
Copyright Owner: Copyright 2012 Elsevier Ireland Ltd.
Copyright Statement: This manuscript version is made available under the CC-BY-NC-ND 4.0 license http://creativecommons.org/licenses/by-nc-nd/4.0/
Deposited On: 14 Apr 2016 02:27
Last Modified: 16 Apr 2016 22:29

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