Assessing Risk in Ambulatory Medication Use after Hospital Transitions

Overview: Medication errors and adverse drug events (ADEs) are a significant problem in ambulatory care. Only recently have medication errors and ADEs related to transitions of care from the hospital to ambulatory primary care been studied. Human factors analysis methods are increasingly being adapted for use in healthcare to identify systems failures and their causes. One method is a prospective risk assessment, this method identifies the failures that occur in processes, the risk of failures, and the causes and effects of the failures.

Methods: This 3-year study assessed, from a primary care perspective, the safety of medication use during patient transitions of care from the hospital to the primary care clinic. Researchers performed a prospective risk assessment of the medication information management (MIM) process from the personal care professional’s perspective. The team interviewed and observed nurses, physicians, and patients and evaluated electronic information systems at 3 primary care clinics and 2 hospitals. Risk of failures, failure causes, and the effects of failures on the MIM process and patient care were identified. The research team also evaluated error recovery mechanisms and the ways that failures and errors get detected and subsequently corrected.

Aim #1: The project analyzed the system failures in the MIM process.

Aim #2: The project evaluated the methods for detection of failures and the subsequent correction of failures in the MIM process.

Findings: Despite the use of electronic health records, MIM process failures are common at transitions of care and in primary care. All components of the work system: people, tools and technologies, organizational policies, training and relationships between organizations, task design and performance, and the environment of care contribute to failure occurrence. Clinicians view failures as typical occurrences in the process. Error recovery mechanisms to prevent harm from failures in medication information transfer are commonplace. Cross-clinic analyses are ongoing.

AHRQ Final Report

Funding: Agency for Healthcare Research and Quality (AHRQ)

Tosha Wetterneck, MD, MS
Associate Professor of Medicine
School of Medicine and Public Health
University of Wisconsin-Madison

Patricia Flatley Brennan, RN, PhD
Lillian S. Moehlman-Bascom Professor of Nursing and Industrial and Systems Engineering
Theme Leader, Living Environments Laboratory
University of Wisconsin-Madison

Pascale Carayon, PhD
Procter & Gamble Bascom Professor in Total Quality
Department of Industrial and Systems Engineering
Director, Center for Quality and Productivity Improvement
University of Wisconsin-Madison

G. Talley Holman, PhD
Assistant Professor, Department of Industrial Engineering
Director, Center for Ergonomics
University of Louisville

Mark Linzer, MD
Professor of Medicine, University of Wisconsin-Madison
Division of General Internal Medicine at Hennepin County Medical Center, Minnesota

Maureen Smith, MD, PhD, MPH
Professor, Department of Population Health Sciences, Family Medicine, and Surgery
School of Medicine and Public Health
University of Wisconsin-Madison

Paul D. Smith, MD
Professor, Department of Family of Medicine
School of Medicine and Public Health
University of Wisconsin-Madison