March 2011

Document Type


Degree Name



Dept. of Medical Informatics and Clinical Epidemiology


Oregon Health & Science University


Optimizing medication management is a low hanging fruit towards improving patient safety. However, while it is understood that medication errors are to be minimized, there does not appear to be any systematic method for thinking about exactly how we should go about doing so. Currently, there is not an adequate theoretical understanding of the medication management activities such that we may systematically conceive, discuss and test interventional strategies. This study examined a spectrum of medication management practices performed by various clinicians within a geriatric, long-term care setting. METHODS DESIGN: naturalistic observation Setting: 5 settings in long-term care facilities on the Oregon coast (Lincoln City and Eugene) consisting of physician’s office, skilled and unskilled nursing facilities, pharmacy and home health visits. Subjects: 10 clinicians that performed medication management tasks including several nurses, physician, pharmacist, and pharmacy technician. Sampling: Snowball Sampling - with a goal of identifying representative task types. Data Collection: 14 sessions of naturalistic, non-participant observations and interviews conducted over 11 days (excluding travel), each session consisting of either one working day of each subject or the duration of the defined medication management task. Special attention was paid to the clinician use of cognitive artifacts. Documents were also collected for analysis. Analysis: The observation data was iteratively analyzed, parallel to data collection, with the final analysis organized by individual settings and within them, thematically across all subjects. The themes derived were then synthesized into an explanatory theory drawing from the theories of Distributed Cognition (DCog) and Activity Theory (AT). Results: The study identifies the task types of correspondence and coherence tasks in terms of their distribution across the cognitive space, as well as special task features such as batching and flow, which have implications for how information tools should be designed. A novel theoretical framework is offered to explain these themes. It argues that clinical activities are well modeled as synthesis and propagation of coherence rather than simply information checking and that safety activities comprising of examining information representations for parity (correspondence) (Eg: Medication Reconciliation), form only a subset of the broader safety continuum that is better seen as a consequence of coherence activities. This new theory fills an analytical gap, not fully addressed by existing theories; specifically, non-standardized professional activities distributed across both internal and external cognitive spaces, resulting in the synthesis of coherence from often heterogeneous representations often hosting only incomplete information, needing to be processed within local and general internal knowledge context. Given that this theory was assembled within the clinical informatics context itself, it holds promise as a native perspective for coming up with practical solutions that align well to clinical task realities.




School of Medicine



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