کد مقاله کد نشریه سال انتشار مقاله انگلیسی نسخه تمام متن
516158 1449135 2013 14 صفحه PDF دانلود رایگان
عنوان انگلیسی مقاله ISI
Medication errors in residential aged care facilities: A distributed cognition analysis of the information exchange process
موضوعات مرتبط
مهندسی و علوم پایه مهندسی کامپیوتر نرم افزارهای علوم کامپیوتر
پیش نمایش صفحه اول مقاله
Medication errors in residential aged care facilities: A distributed cognition analysis of the information exchange process
چکیده انگلیسی

BackgroundMedication 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.MethodsThe 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.ResultsThe 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.ConclusionsApplication 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.


► Examined information exchange for medication management in aged care facilities.
► Gaps in the design of medication charts can lead to medication errors.
► Identified lack of coordination mechanisms as potential cause of medication errors.
► Findings inform the design of appropriate interventions like electronic medication charts.

ناشر
Database: Elsevier - ScienceDirect (ساینس دایرکت)
Journal: International Journal of Medical Informatics - Volume 82, Issue 5, May 2013, Pages 299–312
نویسندگان
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