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

Russ, Alissa L. PhD*†‡§; Militello, Laura G. MA; Glassman, Peter A. MBBS, MSc; Arthur, Karen J. PharmD; Zillich, Alan J. PharmD*†; Weiner, Michael MD, MPH*‡§

doi: 10.1097/PTS.0000000000000324
Original Article: PDF Only

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.

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; †College of Pharmacy, Purdue University, West Lafayette; ‡Richard L. Roudebush VA Medical Center; §Indiana University Center for Health Services and Outcomes Research, Indianapolis, Indiana; ∥Applied Decision Science, Dayton, Ohio; and ¶Internal Medicine, Department of Veterans Affairs, Greater Los Angeles Healthcare System, and David Geffen School of Medicine at UCLA, Los Angeles, California.

Correspondence: Alissa L. Russ, PhD, Richard L. Roudebush VA Medical Center VA HSR&D Center for Health Information and Communication, CHIC 1481 W. 10th St, 11-H Indianapolis, IN (e-mail:

Conflicts of Interest and Source of Funding: L.G.M. is co-owner of Applied Decision Science, LLC, a company that studies decision making in complex environments and utilizes the critical decision method. She aided in the design of the cognitive task analysis approach used in this study and trained the interviewer. M.W. has stock in Allscripts and Express Scripts Holding Company. All other authors report no conflicts of interest. This work was supported by a VA HSR&D Career Development Award 11-214 (PI: A.L.R.) along with the Center for Health Information and Communication, Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service, CIN 13-416.

Contributions: A.L.R. developed the funded grant proposal, with input from M.W., L.G.M., A.J.Z., and P.A.G. The incident card was developed by A.L.R. with input from P.A.G., A.J.Z., K.J.A., M.W., and L.G.M. M.W. and K.J.A. served as the primary physician and pharmacist reviewers, respectively, to evaluate submitted incident cards, with P.A.G. and A.J.Z. as their respective backup reviewers. L.G.M. trained A.L.R. on the critical decision method techniques and helped develop the interview guide. A.L.R. conducted all interviews. Together, L.G.M., A.L.R., A.J.Z., and K.J.A. created the decision requirements template. A.L.R. drafted this manuscript, which was critically revised by all authors and approved before submission.

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