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Barriers Associated with Medication Information Handoffs.


In: Henriksen K, Battles JB, Marks ES, Lewin DI, editors.


Advances in Patient Safety: From Research to Implementation (Volume 3: Implementation Issues). Rockville (MD): Agency for Healthcare Research and Quality (US); 2005 Feb.
Advances in Patient Safety.


Objectives: The transfer of medication information across patient care settings is an important care process handoff with major potential for adverse medical events. This paper reports the results of a recently completed AHRQ project, IDS Solutions for Medication Information Transfer Across Patient Care Settings. A primary objective of this research was to enhance understanding of how patient handoffs are related to risk of adverse medical events before and after implementation of an information technology solution. Methods: A series of key informant interviews with relevant staff was systematically conducted at two hospital facilities to understand the medication information transfer process. This led to an informed pre- and post-evaluation of an implemented information technology (IT) solution. Results: Based on thematic analysis of qualitative data, we identified information barriers due to work processes, role definitions, and individual discretion. Underlying these barriers are more basic technical, structural, and cultural challenges that affect the ability of IT to solve the problems inherent in handoffs across diverse settings. Conclusions: Results from this study can be used to inform future research, drive targeted quality improvement interventions and process redesign, and underscore the need to coordinate care across patient care settings to improve patient safety.

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