Medication decision-making for patients with renal insufficiency in inpatient and outpatient care at a US Veterans Affairs Medical Centre: a qualitative, cognitive task analysis

Abstract

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.

Keywords: health and safety; medical education and training; nephrology; qualitative research.

Figure 1

Descriptive model of HCPs’ decision-making process for renal-drug problems. This depiction is derived from 21 renal-drug incidents. This model illustrates the cyclical nature of stages that HCPs used to manage patients with renal insufficiency. The larger circle of the ‘detect’ stage reflects its important contribution to one of the three main study findings (ie, HCPs reliance on their own vigilance).

Figure 2

Description of how the three stages of healthcare professionals’ renal-drug decision-making differed depending on whether the medication was renally eliminated or nephrotoxic. ¹From 15 incidents. ²From six incidents. ³All 20 HCPs used more than one cue to detect each renal-drug problem. HCPs, healthcare professionals; HCTZ, hydrochlorothiazide.