Intravenous infusion practice as a complex cognitive system: Exploring layers of Distributed Cognition

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Dominic Furniss, University College London

Intravenous (IV) infusion practice involves the delivery of drugs, fluids, blood products or nutrients directly into the patient’s vein, via gravity or some manual or programmable pumping mechanism, e.g., an infusion pump. IV infusion practice has been recognised as a significant topic of concern by regulators, manufacturers and hospital managers due to the frequency and harm related to IV medication errors (AAMI/FDA 2010). It is important to understand different IV practices to configure systems that foster quality and safety.

We take a Distributed Cognition (DCog) (Hutchins, 1995) perspective to investigate IV infusion practice. DCog has been criticised for not having an off the shelf methodology (Rogers, 1997). Distributed Cognition for Teamwork (DiCoT) (Blandford & Furniss, 2006) was developed to fill this gap. More recently, DiCoT-CL (Furniss et al., 2015) introduced concentric layers to the framework to explore how a glucometer was coupled to different layers of the sociotechnical system, i.e. how it influenced and was influenced by the system it was embedded within. We here use this framework for exploring the variance and complexities in IV infusion practice.

We use data from an on-going study, which aims to explore the landscape of IV infusion practices and errors in England across 16 sites (Blandford et al. submitted)

Date & time

7-8 June 2016

NCTL Learning and Conference Centre, Nottingham

What is a Complex System?

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