Nurse Prospective Memory Demands in Inpatient Medication Administration: Gaps and Design Opportunities
TimeWednesday, April 1412:30pm - 12:50pm EDT
LocationPatient Safety Research and Initiatives
DescriptionBackground and Objectives:
Despite being widely studied, medication administration errors (MAEs) remain a persistent problem in healthcare, with errors ranging from 10 to 50% in inpatient units (Berdot et al., 2013; Keers, Williams, Cooke, & Ashcroft, 2013b; McLeod, Barber, & Dean Franklin, 2013; Raju, Thornton, Kecskes, Perry, & Feldman, 1989; Rodriguez-Gonzalez et al., 2012). MAEs refer to deviations during administration from the prescribed medication order, preparation and dispensing instructions, or regulatory guidelines(Keers et al., 2013b). Current approaches that apply general error taxonomies to classify types of MAEs find that lapses – memory-related failures due to issues with encoding, retaining, and recalling information (Reason, 2002) – account for a substantial proportion of MAEs (Keers, Williams, Cooke, & Ashcroft, 2013a, 2015). Prospective memory (PM), which is remembering information that must be acted on in the future, is a frequent memory process used by nurses during medication administration and is a potentially significant source of the memory lapse errors. The goal of our project was to uncover the medication administration workflow, including tasks during planning, dispensing, administration, documentation, and monitoring.
We conducted semi-structured interviews with fourteen nurses working on medical/surgical units. Interview guides were structured to elicit general PM demands embedded in each stage of the workflow and specific types of PM demands based on the literature in cognitive psychology. Nurses were drawn from three hospitals in a large healthcare system in the mid-Atlantic. Interviews were conducted remotely, audio-recorded, and transcribed. Nurses received compensation for participation, and the study was approved by the IRB. Grounded theory was used to code interview themes.
We uncovered several nuances and varieties of PM tasks imposed on nurses during medication administration, including:
• Time-based PM tasks: tasks that must be remembered to be performed at a specific time of the day (e.g., remember to give medications at 9am), at regular intervals of time (e.g., monitoring a patient’s fluid intake and output every four or eight hours to check patient’s response to some medications), after a specific amount of time has passed (e.g. evaluating the effectiveness of pain medication one hour after administration)
• Event-based PM tasks: tasks that must be remembered to be performed after the occurrence of a specific event (e.g., remember to add a medication to the list after multidisciplinary rounds), before performing a task (e.g., checking pre-meal blood sugars), after performing a task (e.g., administering sliding scale insulin), and after waiting for a delay (e.g. administering an antibiotic when a patient returns from dialysis)
• Cues that help nurses recognize the moment of opportunity to execute the PM task
• Strategies and tools that nurses use to remember PM tasks impacting medication administration (e.g., listing tasks on a paper tool, annotating and highlighting tasks on the tool to track the task’s nature and completion status, writing tasks on their hand or scrubs, using electronic tools in the EHR to remember tasks, using alarms on cell phones, writing tasks on whiteboards in patient rooms)
• Ideas on design features of tools that can help nurses encode and remember medication-related PM tasks
Key take-aways and Directions for Future Research:
• The medication administration workflow in inpatient settings is complex and encompasses a variety of PM tasks. PM failure is likely to have adverse patient safety implications because of heightened risk of medication administration errors.
• PM tasks can be anticipated during medication planning; however, several PM tasks also arise dynamically depending on changes to the patient’s condition or because of changing nurse or unit workflow priorities.
• Although PM tasks that arise during planning are amenable to being encoded as reminders on the EHR and nursing paper tools (“nurse brains”), there is a need to develop tools to improve support for PM tasks that arise dynamically.