We describe a phenomenon viewed through the conceptual lens of a naturalistic decision making perspective: a loss of system resilience, due to increased difficulty in performing macrocognition functions, associated with the implementation of new information technology. Examples of the phenomenon collected in a targeted literature review are characterized by stakeholder groups, technology, typical changes in workflow before and after implementation, and potential impacts on macrocognition and patient outcomes for four clinical care environments. The loss of system resilience is due to increased difficulty in performing macrocognition functions: 1) sensemaking due to less effective cognitive warm-up and collaborative framing strategies, 2) detecting events due to missing trends in data and changes to orders, and 3) coordinating due to less clinical knowledge during scheduling and updating information, and less effective cross-checks. Potential impacts to patient safety include an increase in unnecessary care, missed care, delays in diagnoses and treatment, redundant care, inaccurate diagnoses, medication errors, and adverse events. We recommended future conceptually-driven research in other complex, sociotechnical settings order to develop useful metrics and reduce the risk of incurring undesirable and unnecessary impacts on cognitive work associated with new technology.

Background

Many studies identify factors that contribute to renal prescribing errors, but few examine how healthcare professionals (HCPs) detect and recover from an error or potential patient safety concern. Knowledge of this information could inform advanced error detection systems and decision support tools that help prevent prescribing errors.

Objective

To examine the cognitive strategies that HCPs used to recognise and manage medication-related problems for patients with renal insufficiency.

Design

HCPs submitted documentation about medication-related incidents. We then conducted cognitive task analysis interviews. Qualitative data were analysed inductively.

Setting

Inpatient and outpatient facilities at a major US Veterans Affairs Medical Centre.

Participants

Physicians, nurses and pharmacists who took action to prevent or resolve a renal-drug problem in patients with renal insufficiency.

Outcomes

Emergent themes from interviews, as related to recognition of renal-drug problems and decision-making processes.

Results

We interviewed 20 HCPs. Results yielded a descriptive model of the decision-making process, comprised of three main stages: detect, gather information and act. These stages often followed a cyclical path due largely to the gradual decline of patients' renal function. Most HCPs relied on being vigilant to detect patients' renal-drug problems rather than relying on systems to detect unanticipated cues. At each stage, HCPs relied on different cognitive cues depending on medication type: for renally eliminated medications, HCPs focused on gathering renal dosing guidelines, while for nephrotoxic medications, HCPs investigated the need for particular medication therapy, and if warranted, safer alternatives.

Conclusions

Our model is useful for trainees so they can gain familiarity with managing renal-drug problems. Based on findings, improvements are warranted for three aspects of healthcare systems: (1) supporting the cyclical nature of renal-drug problem management via longitudinal tracking mechanisms, (2) providing tools to alleviate HCPs' heavy reliance on vigilance and (3) supporting HCPs' different decision-making needs for renally eliminated versus nephrotoxic medications.