An important part of ensuring patient safety is the effective transmission of medication information across care settings. Inaccurate or incomplete information is a leading cause of medical error. This research project focuses on information exchange between ambulatory care and acute care settings. The purpose of this study was to gain an in-depth understanding of the medication information transfer process and identify likely process failures, which can be practically addressed. This qualitative study used various data collection approaches to improve our understanding of the medication information transfer process. A series of focus groups with clinicians at Providence Health System provided the basic foundation of information for creating a generic care process model. The following were key findings from PHS focus groups: (1) Breakdowns in medication information transfer were a problem that concerned clinicians, who believed that these breakdowns were definitely a source of adverse medical events. (2) Medication information transfer was not a single process, but rather a complex set of overlapping processes that engaged multiple caregivers and depended on source of admission and discharge destination. (3) Clinicians expected that patients and their family members would serve as a reliable source of information. (4) Medication information education with patients/family is often limited to new medications (versus a comprehensive review of all prescribed medications). (5) Information technology as a solution for enhancing medication information transfer had mixed success.
PIC ID: 7682
Agency Sponsor: AHRQ, Agency for Healthcare Research and Quality
Federal Contact: Morgan, Kelly, 301-594-1782
Performer: Research Triangle Institute, Research Triangle Park, NC