Table 2.

Care Coordination Strategies That HCPs Used to Facilitate the Delivery of Healthcare Services for Patients Involved in Medication Safety Incidents

Strategy	Definition	Examples
Cognitive decentering	Instances where a participant attempted to assume the perspective of another HCP during the incident.	“I went back to the last renal note….to get from renal’s perspective what they actually thought caused this [patient’s renal failure].”—physician #1 “any time a doctor ever calls me [for advice]…I ask them to give me their take on it and at the same time I’m validating what they’re telling [me] as I’m reading through the chart…”—pharmacist #1
Offering pharmacotherapy recommendations and engaging in collaborative decision-making*	Instances where one HCP communicated with at least one other HCP regarding drug-related therapy during the incident.	“I sent the note to the oncologist. [I wrote] ‘Patient’s PPI [proton pump inhibitor] was discontinued due to a drug interaction for erlotinib ….do you have any suggestions on what would be the safest option for reflux?’”—physician #2
Back-up behaviors	Situations such as one HCP covering another, a participant conducting multiple actions to increase safety redundancy, or the participant tracking the work of another HCP to ensure that safety recommendations were carried out.	“.…I do like to keep the file because I feel like sometimes the doctors don’t address things appropriately and I have to go back and make sure that they have….”—pharmacist #2
Contingency planning	Alternative steps conceived or considered by the participant, but not actually carried out for “what if” scenarios, in the event that some aspect of the incident had been different (e.g., change in patient’s health status), or their initial efforts to address the safety concern were unsuccessful.	“So if [the oncologist] had been on vacation or I couldn’t get ahold of her…I might have asked my [clinical] pharmacist to contact the oncology pharmacist and see if they have any suggestions. That would’ve been another route.”—physician #2

HCP, healthcare professional

*This includes both unidirectional communication (e.g., electronic health record (EHR) notification) as well as joint discussion to inform medication decisions, regardless of modality. Various modalities were used, such as in-person planned and spontaneous discussions, phone calls, e-mail, EHR co-signer requests, addenda to EHR documentation, and EHR notifications. Examples were found from all four combinations of participant categories: pharmacist to physician, physician to pharmacist, pharmacist to pharmacist, and physician to physician