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

Alissa L. Russ, Laura G. Militello, Peter A. Glassman, Karen J. Arthur, Alan J. Zillich, Michael Weiner

Research output: Contribution to journalArticle

1 Scopus citations


Objectives 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. Methods 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. Results 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. Conclusions 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.

Original languageEnglish (US)
Pages (from-to)191-197
Number of pages7
JournalJournal of Patient Safety
Issue number3
StatePublished - Sep 1 2019


  • cognitive task analysis
  • decision making
  • electronic health records
  • health services research
  • incident investigation
  • medication safety

ASJC Scopus subject areas

  • Leadership and Management
  • Public Health, Environmental and Occupational Health

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