Using Cognitive Ergonomics and Metacognition Processes for Understanding and Improving Medication Safety Systems

Cognitive ergonomics implies understanding how people make decisions, and how to design safer systems for the people involved. Understanding how experts in medication safety management think and make decisions, give a new vision of how to design safer systems. A study was achieved for characterizing ergonomic cognitive and metacognitive processes developed by some experts in medication safety (pharmacists, doctors, nurses) solving problems related to unsafe medication (prescription, preparation, dispensing, and administration). Using a “think aloud” methodology was possible to identify how the experts think and which are the principles to have in mind for designing safer medication management processes. We found that the experts think about the goal in a task, balancing how to keep a Patient out of risk against it, this requires planning and developing task-oriented thinking in mitigating every risk rather than just performing the task. While monitoring the task, experts reflect on whether the patient is responding in the same way as would be expected. Any alteration of the medication’s therapeutic effect may be the result of a possible mistake. They find a better way of controlling the task by taking alternative decisions using their knowledge and previous experiences for developing their task. Using a critical mindset, they modify their actions dynamically in the process. Finally, evaluation includes a metacognition process to identify improvement opportunities, which could be used in situations they might face later. Using cognitive and metacognitive process descriptions is possible to design a safer medication system.