A Memory-Based Approach to Reducing Medication Errors

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PROJECT SUMMARY Despite being widely researched, between 10 to 50% of inpatient medication administration instances are associated with errors. Memory lapses are a common cause of medication administration errors (MAE). 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. PM tasks during medication administration arise when nurses must remember to perform important medication-related tasks in the future, such as remembering to check for interactions before administering medication, and remembering to resume tasks that are interrupted during medication administration. Managing PM demands in high-risk, high-volume medical/surgical units in which nurses manage up to eight patients, with each patient being scheduled on average 25 medications per day, is especially challenging, and may leave nurses at risk for committing MAEs. Our proposal will use a cognitive psychology- based approach, with a focus on PM, to identify PM demands during medication administration. We will use sociotechnical systems theory to identify high-risk moments during medication administration where PM may be unsupported by the sociotechnical system and increase the likelihood of MAEs. We will also analyze medication errors through data generated by technologies in the inpatient medication prescription to administration cycle and align these data with PM demands to provide unique insights into the association between medication errors and PM demands. Our proposed research includes the following: Specific Aim 1: Identify and quantify nurse PM demands during medication administration through interviews and direct observations. Specific Aim 2: Identify and quantify medication errors by analyzing technology usage data in the inpatient medication cycle (i.e., prescription, dispensing, administration, and documentation), and align medication errors with observed PM demands. Identifying memory demands of nurses during medication administration presents an opportunity for future work to develop memory aids and health information technology to support PM needs to reduce MAEs.