Send to

Choose Destination
J Patient Saf. 2017 May 3. doi: 10.1097/PTS.0000000000000324. [Epub ahead of print]

Adapting Cognitive Task Analysis to Investigate Clinical Decision Making and Medication Safety Incidents.

Author information

From the *Center for Health Information and Communication, Department of Veterans Affairs (VA), Veterans Health Administration, Health Services Research and Development Service (CIN 13-416) and Regenstrief Institute, Inc., Indianapolis; †College of Pharmacy, Purdue University, West Lafayette; ‡Richard L. Roudebush VA Medical Center; §Indiana University Center for Health Services and Outcomes Research, Indianapolis, Indiana; ∥Applied Decision Science, Dayton, Ohio; and ¶Internal Medicine, Department of Veterans Affairs, Greater Los Angeles Healthcare System, and David Geffen School of Medicine at UCLA, Los Angeles, California.



Cognitive task analysis (CTA) can yield valuable insights into healthcare professionals' cognition and inform system design to promote safe, quality care. Our objective was to adapt CTA-the critical decision method, specifically-to investigate patient safety incidents, overcome barriers to implementing this method, and facilitate more widespread use of cognitive task analysis in healthcare.


We adapted CTA to facilitate recruitment of healthcare professionals and developed a data collection tool to capture incidents as they occurred. We also leveraged the electronic health record (EHR) to expand data capture and used EHR-stimulated recall to aid reconstruction of safety incidents. We investigated 3 categories of medication-related incidents: adverse drug reactions, drug-drug interactions, and drug-disease interactions. Healthcare professionals submitted incidents, and a subset of incidents was selected for CTA. We analyzed several outcomes to characterize incident capture and completed CTA interviews.


We captured 101 incidents. Eighty incidents (79%) met eligibility criteria. We completed 60 CTA interviews, 20 for each incident category. Capturing incidents before interviews allowed us to shorten the interview duration and reduced reliance on healthcare professionals' recall. Incorporating the EHR into CTA enriched data collection.


The adapted CTA technique was successful in capturing specific categories of safety incidents. Our approach may be especially useful for investigating safety incidents that healthcare professionals "fix and forget." Our innovations to CTA are expected to expand the application of this method in healthcare and inform a wide range of studies on clinical decision making and patient safety.

Supplemental Content

Full text links

Icon for Wolters Kluwer
Loading ...
Support Center