Resolving medication errors often requires coordination between different care providers. This qualitative study examined medication safety incidents at one VA hospital and found that health care providers rely on cognitive decentering, collaborative decision-making, back-up behaviors, and contingency planning to coordinate care during medication safety incidents. The primary barriers to care coordination identified were role ambiguity, breakdowns in care, and electronic health record-related challenges.

… J Patient Saf … J Patient Saf … Cognitive task analysis is a human factors …

… Am J Health Syst Pharm … Am J Health Syst Pharm … Nuisance drug alerts generated by smart …

Changes in processes, devices, and technologies can increase risk of human error. This commentary discusses how switching from one smart pump system to another can have unintended consequences and recommends tactics to prevent the problems associated with implementing new technology from reaching patients.