Table 4.

Proposed Systems Interventions That Might Prevent or Address Medication Safety Incidents. These ideas for system solutions were derived from hcps’ statements during interviews, discussion between the pharmacist and human factors engineer in stage 1 of the qualitative analysis, identified decision requirements, and iterative, monthly input from the entire research team, which included pharmacists, physicians, and a sociologist and human factors psychologist. ideas below should be pilot tested and evaluated for effectiveness, effects on hcps’ workload, and unintended consequences before deciding whether to implement them on a larger scale

Challenge related to care coordination	Potential intervention
i. HCPs unaware of safety incidents caused by medications they prescribed.	• Automated communication of incidents. Implement intelligent systems that automatically notify HCPs when “trigger” events occur regarding ADE symptoms to medications they have prescribed (e.g., patient presents to emergency department with medication-related symptoms). Display this information, too, on the corresponding EHR medication order and medication list, to guide future medication decisions and decrease the chance of inappropriate medication renewal and re-ordering.
ii. Difficulty locating safety-critical documentation in the EHR about the intended plan for the patient’s medication, such as why a medication was discontinued, and whether that medication is appropriate to be restarted.	• Semi-automated documentation specifically for unsafe orders. Develop and implement a semi-automated documentation mechanism tied to specific medication orders (rather than just progress notes), to explain past and future safety-related plans for individual medication orders.        Viewable by all HCPs. Persistently displayed on the EHR medication list and on the CPOE screen (if an HCP attempts to modify or re-order the medication).        If a medication is discontinued or dose is reduced for safety, provide easy mechanisms to document a reason for the change, along with their recommendation about whether it might be appropriate to re-start in the future. For any given medication, all such reasons would then be displayed when that medication is ordered again at a future time.        Intelligent CPOE design that warns the prescriber or helps prevent re-ordering of patients’ past medications that were stopped for safety reasons. • Some medication actions could be automatically documented by the EHR: it could track and display what changes were made to an individual medication order over time, and by whom, along with contact information for that HCP. (Some EHRs may have this function already, with room to improve data visualization.)
iii. Inability to reach other HCPs or find their contact information to resolve incidents.	• Transparent HCP availability, shown via the EHR. Leverage HCPs’ EHR login status to indicate real-time availability to other HCPs, along with what day(s) of the week or month that specialists, part-time HCPs, and those that rotate through the organization are available. (HCPs in some organizations use instant messengers such as Skype to assess others’ presence and availability, but presenting this in the EHR may aid security and could reduce cognitive burden for HCPs since all information would be in one place, located in close proximity to their clinical tasks.) • EHR-integrated directory of all HCPs. Ideally, this information would be available throughout the EHR, whenever an HCP name is listed. Within the EHR, also provide a complete, up-to-date directory of contact information listing all HCPs in the organization, with the ability to search by provider type, specialty (e.g., oncology pharmacist), name, and on-call status. This list should include HCPs’ phone numbers, pagers, e-mail (for communications that do not involve protected health information), and alternative contact information in case they cannot be reached during urgent safety incidents. • HCP contact information displayed for each medication order. Within the EHR, indicate the prescriber name associated with each medication order, along with an easily accessible link or display of that HCPs’ contact information. Request that each prescriber designate a preferred contact modality regarding their prescriptions; display this in the EHR with the order. This could provide pharmacists with guidance about the best way to reach specific prescribers.
iv. Uncertainty among HCPs regarding appropriate communication modalities during safety incidents.	• National or organizational guidelines for safety communication modalities.        Develop and implement national or organizational guidelines, and provide training regarding appropriate communication mechanisms to use to coordinate care during patient safety incidents (e.g., “If the safety concern needs to be addressed within 48 h, contact the prescriber by phone.”).        Specify under what safety circumstances multiple communication modalities should be used simultaneously.        Incorporate guidelines into patient safety culture and patient safety curricula across healthcare professionals.
v. Delayed action when unsafe medication orders require attention.	• Consider increasing pharmacists’ scope of practice for safety-critical medication changes, so these concerns can be addressed more directly and quickly. • Develop advanced tools to help physicians track information across their own panel of patients, and promote completion of medication safety actions. • Improve communication mechanisms for rejected prescriptions. Develop more effective approaches to notify prescribers about inappropriate orders, along with communication modalities to help resolve these situations to proceed with an alternative treatment plan.

ADE, adverse drug event; CPOE, computerized provider order entry; EHR, electronic health record; HCP, healthcare professional