Applied Ergonomics 90 (2021) 103279

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Applied Ergonomics
journal homepage: http://www.elsevier.com/locate/apergo

Medication transitions: Vulnerable periods of change in need of human

factors and ergonomics
Richard J. Holden a, b, c, *, Ephrem Abebe d
a
Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
b
Indiana University Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, IN, USA
c
Center for Health Innovation and Implementation Science, Indiana University School of Medicine, Indianapolis, IN, USA
d
Purdue University College of Pharmacy, West Lafayette, IN, USA

A R T I C L E I N F O A B S T R A C T

Keywords: We present a novel view of transitions from the lens of patient ergonomics (the “science of patient work”), which
Patient work posits that patients and other non-professionals perform effortful work towards health-related goals. In patient
Patient engagement work transitions, patients experience changes in, for example, health, task demands, work capacity, roles and
Patient ergonomics
responsibilities, knowledge and skills, routines, needs and technologies. Medication transitions are a particularly
Transitions of care
Medication safety
vulnerable type of patient work transitions. We describe two cases of medication transitions—new medications
Medical human factors and medication deprescribing—in which the patient work lens reveals many accompanying changes, vulnera­
bilities, and opportunities for human factors and ergonomics.

In this paper we present a novel view of transitions from the lens of
patient ergonomics, i.e., the “science of patient work” (Holden et al.,
2020b). Patient ergonomics assumes that patients (and others) perform
effortful work towards health-related goals (Yin et al., 2020) and that
human factors and ergonomics (HFE) approaches can be applied to
study and support this work (Holden et al., 2013). Viewed through a
patient ergonomics lens, transitions may be described as changes in the
nature and conditions of the patient’s work. Below, we present several
examples of transitions in patient work. We particularly elaborate on
medication transitions: the vulnerable periods surrounding
medication-related changes. To conclude, we discuss how research
methods and interventions in the HFE literature on transitions of care
can be applied to study and improve transitions in patient work.
1. Contrasting views of transitions
The conceptualization of transitions is a matter of perspective. From
one point of view, transitions occur when a patient has moved from one
setting of care to another or when the patient’s care was passed between
clinicians (or clinical teams) (Fig. 1a) (Coleman and Boult, 2003; World
Health Organization, 2016). This is the traditional definition under­
pinning most of the studies in the literature, including those in this
special issue. This is the view of transitions seen through the lens of
clinician workers: as on a production line, the clinician works on a pa­
tient as they arrive, then passes them downstream.1 The principal goal in
this model is continuity, whether between settings, shifts, or clinicians.
Interventions towards the continuity goal include standardized hand­
over or discharge procedures and forms, reconciliation of discrepancies
(e.g., between pre- and post-hospital medications), and the use of clin­
ical monitoring, home visits, and follow-up appointments (Chhabra
et al., 2012; Feltner et al., 2014; LaMantia et al., 2010). Patients in this
view play a relatively passive role and receive only education, if any­
thing (Dyrstad et al., 2015).
A contrasting view of transitions can be seen through the lens of
patient work (Fig. 1b). Patient work is the notion that patients, and
sometimes their network of informal caregivers (Lambotte et al., 2020),
perform effortful activities towards health-related goals (Valdez et al.,
2015). The accomplishment of these goals depends on how well the
sociotechnical system around the patient was designed to support their
performance, much like the case for any other worker (Holden et al.,

* Corresponding author. Regenstrief Institute (RF) 421, 1101 W 10th Street, Indianapolis, IN, 46202, USA.
E-mail address: rjholden@iu.edu (R.J. Holden).
1
We anticipate the production line is a provocative metaphor. It is our intent to contrast perspectives on who does the work, not to insinuate clinicians view
patients as something they are working on. However, others have reported findings suggesting the language of handovers objectifies patients as seen in metaphors of
“sales” or “packaging” Hilligoss, (2014). Our broader point is patients and clinicians both work to coproduce health and healthcare outcomes Ocloo & Matthews,
(2016)

https://doi.org/10.1016/j.apergo.2020.103279
Received 24 July 2019; Received in revised form 22 September 2020; Accepted 28 September 2020
Available online 10 October 2020
0003-6870/© 2020 Elsevier Ltd. All rights reserved.
R.J. Holden and E. Abebe
2015a,b; Holden et al., 2017). Transitions of patient work, then, are
situations when a change has taken place, altering the nature or con­
ditions of a patient’s work. This change can, but need not, be caused by
or co-occur with changes in care settings or teams. For illustration,
Table 1 exemplifies several types of changes in patient work during
hospital-to-home transitions drawn from two recent studies (Werner
et al., 2018; Xiao et al., 2019).
These changes, and many others, may result from various situations,
not only during transitions as traditionally defined (Fig. 1a). Other sit­
uations bringing about patient work transitions might be new pre­
scriptions or adjustments to medications, the onset or resolution of a
chronic or acute condition, life events (e.g., marriage or divorce,
childbirth or death, a new job or retirement), moving to a new residence
or city, the implantation of a new device (e.g., defibrillator), or simply
the passage of time and seasons. Importantly, these transitions are
vulnerable periods for patients because the timing, volume, and nature
of changes may disrupt or otherwise complicate the performance of
patient work. For example, after a new diagnosis, a patient is likely to
lack information and face fear and anxiety due to high levels of uncer­
tainty; thereafter, they will likely undergo phases of information work in
service of longer-term goals such as maintaining routines and emotional
acceptance, in addition to new bouts of learning (Burgess et al., 2019;
Daley et al., 2019). As another example, new medication prescriptions
may be accompanied by the risk of unintentional nonadherence due to
forgetting or challenges related to paying for or managing drug supply
(Barber, 2002; Mickelson and Holden, 2018). As a third example,
changes in health may leave a person less able to cope with the burden of
treatment, which, ironically may increase as a person becomes sicker,
due to new medications, procedures, and self-care recommendations
(Shippee et al., 2012; Van Merode et al., 2018). Importantly, we contend
that HFE can mitigate risks in patient work transitions by studying and
intervening to support patient work during these vulnerable transition
periods.
2. Medication transitions
To illustrate our point, we focus on medication transitions, a
particularly common and risky type of transitions in patient work. A
medication transition occurs when there is a change in medication,
whether it is a new medication, the deprescribing (discontinuation or
replacement) of current medications, modification in the prescription or
administration regimen, or emergence of new circumstances that shape
how patients take their medications. In outpatient and community set­
tings, these transitions are tremendously impactful on patient work
(Xiao et al., 2019), as in these two cases:
2.1. Case 1: new medications
Mr. Smith is a 45-year old who has been living with Type-2 diabetes
mellitus for several years now. About six months ago, he was given a
prescription for a once-daily insulin (insulin glargine) on top of the
Metformin tablets he was already taking. He was instructed to inject
Fig. 1. Two lenses to see transitions from the points of view of: (a) clinical vs. (b) patient work.
2
Applied Ergonomics 90 (2021) 103279
Table 1
Types of changes a patient may experience in addition to changes in the setting
of care, following hospital discharge.
Types of change Examples
Health From feeling well to feeling poorly, or vice versa
Task demands New tasks, e.g., handling insurance matters, attending new
appointments, or recording daily weight and blood pressure
readings
Capacity Weakened physiological reserve, but increased family aid
Roles and From being monitored and cared for by a clinical team to
responsibilities self-monitoring and self-care, or vice versa
Knowledge and skills Learning about new medications and how to use them
Routines Re-establishing an exercise regimen or establishing new
habits, such as reading nutritional labels and preparing low-
sodium meals
Needs From medical-physical needs, to social-emotional needs
related to coping with anxiety and coming to terms with
illness
Technology Obtaining and learning to use new equipment
insulin into his abdomen every evening. During his most recent clinic
visit, he was prescribed with a rapidly-acting insulin analog pen injector
(insulin lispro). He was instructed to take “two of these”. He was also
told to measure and keep track of his blood sugar but never received a
measuring kit, despite his provider writing a prescription for it. The next
day, his daughter, who lives a few blocks down the street, was visiting
Mr. Smith and discovered him lying on the floor, profusely sweating, and
confused. She called an ambulance and he was rushed to the emergency
room (ER).
In the ER, it was determined that he had experienced hypoglycemia
and was treated for it. Upon further examination, Mr. Smith told the
team that he had injected himself with two doses of the new insulin at
once, having dialed 12 units on the insulin pen each time before the
injection. He stayed overnight in the ER and was discharged home the
following day.
A long-time friend of Mr. Smith who had heard of the incident was
visiting him at his house and mentioned about a new blood sugar
measuring device prescribed to his granddaughter and one “she wears
all the time.” Mr. Smith is very scared of having another episode of
hypoglycemia especially due to the fact that he lives alone and help may
not arrive in time.
During their ensuing conversation, Mr. Smith also comments to his
friend how expensive it was to get the new insulin and he was not sure if
he is able to continue taking it.
2.1.1. Commentary
The act of writing a new prescription order can be viewed as a critical
moment in which the clinician transfers greater responsibility to a pa­
tient, effectively making the patient a full-fledged medication manager
(Foust et al., 2005). In the above example, Mr. Smith experienced
multiple medication-related transitions, stemming from initiation of a
new medication—insulin lispro. The change was associated with a
potentially life-threatening incident. Adding the new insulin to Mr.
R.J. Holden and E. Abebe
Smith’s existing regimen introduced new demands: developing new
skills (e.g., operate insulin pen, self-inject insulin, measure and track
blood sugar levels); acquiring new knowledge (e.g., how insulin works,
what benefits it has, differentiate new insulin from existing, night time
insulin); creating new routines (e.g., coordinate with meal, schedule
with respect to other medications); and acquiring new strategies (e.g.,
detecting signs of and responding to hypoglycemia). Patients with Type
2 diabetes are likely to be prescribed multiple medications including
those to treat high blood pressure, reduce clotting tendency, manage
cholesterol, and control neuropathic pain.
Although Mr. Smith had been living with diabetes for many years, he
is relatively new to insulin and vulnerable to adverse effects. He has
been on a long acting insulin for 6 months before his provider intro­
duced the insulin lispro. This is a common management strategy in
patients with Type 2 diabetes exhibiting signs of treatment failure with
oral therapies such as sulfonylureas. Although both forms of insulins act
in the same fashion, they exhibit key distinctions with respect to their
release profile and how quickly they can lower blood sugar. This has
important implications on when and how each type of insulin must be
injected. This knowledge may not be apparent to Mr. Smith. Given his
experience of injecting the long acting insulin once per night, it is
possible that Mr. Smith misunderstood the instruction with his insulin
lispro.
Given his medical history, Mr. Smith will continue to need insulin,
with a possibility of introducing an even more intensive insulin regimen.
This situation will demand frequent monitoring of blood sugar to adjust
his insulin doses. This may mean, however, more burden for Mr. Smith
as he has to regularly perform blood sugar self-measurement. Mr. Smith
had heard about the continuous glucose monitoring device from his
friend and does not know if that will be something he can try out.
However, the out-of-pocket expense may be prohibitive for him, even if
his doctor is willing to prescribe the device for him. He would also need
to learn how to change the sensor every 10 days. Mr. Smith also
expressed concern about the cost of his insulin. This may prompt him to
discontinue or ration his insulin dose so it can last him longer, at a risk of
poor glycemic control and progression of chronic diabetic complica­
tions. A cheaper form of insulin sold in a vial may be used as an alter­
native. However, Mr. Smith’s provider may be reluctant to agree
because of limited personal experience with this form of insulin and
concern about Mr. Smith’s capacity to measure and draw accurate
amounts of insulin from the vial.
2.2. Case 2: deprescribed medications
Ms. Nguyen is a 65-year old chronic joint pain sufferer experiencing
regular sleep disturbances. For years, her physician prescribed diphen­
hydramine for her sleep and occasionally she would self-administer a
nighttime over-the-counter product for pain (e.g., acetaminophen).
During a regular appointment, her primary care physician recom­
mended that given Ms. Nguyen’s age, they should change her medica­
tions. The physician wrote an order to discontinue the diphenhydramine
but did not explain that diphenhydramine is an ingredient found in over-
the-counter medicines such as Benadryl® and Tylenol® PM. Later in the
visit, Ms. Nguyen admitted to the nurse she was worried about what
would happen “now that the doctor took away my sleep pill.” The nurse
suggested Ms. Nguyen buy over-the-counter melatonin.
At home, Ms. Nguyen shared with her daughter-in-law her concern
about sleep and the change in her medication. This prompted the
daughter-in-law to investigate online and to learn that anticholinergic
medications such as diphenhydramine are associated with incident de­
mentia and mild cognitive impairment. From then on, Ms. Nguyen
received at least one email per day from her daughter-in-lawwith a new
article, or website, or exhortation to avoid anticholinergics. This raised
Ms. Nguyen’s anxiety about developing dementia—after all, she had
been taking her sleep medication for years—on top of her prior anxiety
about getting a good night’s sleep. The emails also confused her by
3
Applied Ergonomics 90 (2021) 103279
introducing unfamiliar and soundalike words such as anticholinergic,
antihistamines, diphenhydramine, and dimenhydrinate. She was espe­
cially perplexed by her daughter-in-law’s recommendation to buy “over-
the-counter ZzzQuil™ with the white label but not the all-purple
ZzzQuil™.”
After a week of confusion, Ms. Nguyen went to the grocery store and
stood paralyzed in front of the hundreds of products on the over-the-
counter shelves. Her eyes flitted from package to package, drawn to
pictures of sheep, moons, pillows, clouds, and feathers. She noticed all
packages of ZzzQuil™ were both purple and white; she could not tell the
difference between what was presumably safe or unsafe for her (i.e.,
ZzzQuil™ with diphenhydramine vs. ZzzQuil PURE Zzzs™ with mela­
tonin). In fact, all the products she looked at seemed safe, proclaiming
themselves “clinically tested,” “proven effective,” “natural sleep for­
mula,” and “non-habit forming.” Frustrated, Ms. Nguyen dismissed her
fear of seeming stupid, picked up a product marked “#1 pharmacist
recommended” and marched up to the pharmacist’s counter, pro­
claiming “It says here you recommend this stuff—is it going to help me
sleep or give me dementia?” In the end, with the pharmacist’s help, Ms.
Nguyen bought the ZzzQuil PURE Zzzs™ product, although she was not
happy with its price. On her way back through the aisles, she stopped to
resupply her pain medication, purchasing several boxes of Tylenol® PM,
without realizing that the “nighttime” version of popular brand of
acetaminophen also contained diphenhydramine, the very medication
her physician had deprescribed.
In the end, and on the advice of a pain specialist, Ms. Nguyen became
dissatisfied with using medications to manage her insomnia. Instead, she
began to attend a swimming pool for water aerobics, to treat her un­
derlying pain issues and promote natural sleep.
2.2.1. Commentary
During this medication transition episode, Ms. Nguyen experienced
several abrupt changes and is likely to experience several more as time
passes. Medication deprescribing is increasingly observed in geriatric
care for several reasons, including to reduce the risk of harmful effects,
drug-drug interactions, and the treatment burden of polypharmacy
(Scott et al., 2015). The deprescribing of anticholinergics (Campbell
et al., 2019), in particular, is recommended to reduce short- and
long-term risks associated with these medications (American Geriatrics
Society, 2019, Richardson et al., 2018).
As with other patient work transitions, deprescribing is accompanied
by many changes with which the patient must cope. For one, depres­
cribing, can cause physiologic changes, including withdrawal and the re-
emergence of symptoms formerly treated by the medication such as pain
or insomnia. In the case of Ms. Nguyen, another change is the intro­
duction of new terms and concepts: antihistamines; anticholinergics;
various specific medications (generic and brand-name); and dementia
risk. Patients may be unaware of these terms; in one study, 100% of
patients using medications with anticholinergic effects were unaware of
the term or its meaning (Holden et al., 2019). Translating knowledge to
action may be even more difficult, as illustrated by Ms. Nguyen’s pur­
chase of an over-the-counter medication (Tylenol® PM) that was
potentially unsafe for her.
When deprescribed medications are substituted with other medica­
tions or non-pharmacological treatments such as exercise, the patient is
challenged to adapt. For Ms. Nguyen, the decision to exercise could have
meant finding a way to exercise despite her joint pain, purchasing new
activewear or swimwear, and finding an accessible water aerobics pro­
gram. Such construction of routines and problem solving have been
observed before in HFE studies of patient work (Holden et al., 2017;
Mickelson et al., 2016; Werner et al., 2018), including documented
in-depth cases of an older patient attempting to find a low-impact,
accessible, and acceptable exercise routine (Holden et al., 2015b) or to
re-establish a self-care regimen after several years of incarceration
(Holden et al., 2015a).
Moreover, deprescribing in Ms. Nguyen’s case led to new out-of-
R.J. Holden and E. Abebe Applied Ergonomics 90 (2021) 103279

pocket expenses for over-the-counter medications, changes in family requirements (e.g., new medication, new disease), contexts (e.g., loss of
dynamics, questions and fears, and a left-over supply of medications. a job, moving to a new city), or life stage (e.g., end of life, parenthood
(Patel et al., 2019)).

2.3. General observations

3. Opportunities for HFE

In the two cases, several medication-related changes occurred, and

Returning to the concept of patient work, we observe that Mr. Smith
neither was caused by an acute event, transition of care, or change in
and Ms. Nguyen are workers, based on their performance of various
care teams. In fact, Mr. Smith’s ER visit and Ms. Nguyen’s encounters
health-related tasks, including self-monitoring their disease conditions,
with multiple clinicians (primary care physician, retail pharmacist,
managing medications, and learning about new health regimens. Patient
nurse, and pain specialist) were incidental to the medication transitions
work interventions seek to support the patient and their informal care
that brought about the many changes these patients experienced. The
partners in performing these tasks by modifying the work system,
changes were physiological, cognitive, emotional, and operational. Each
including introducing new tools and resources, task redesign, and larger-
of them produced vulnerabilities and threatened the patient’s quality of
scale organizational or policy changes (Valdez et al., 2015, 2016). In­
life, adherence, financial wellbeing, family relations, and day-to-day
terventions to improve Mr. Smith’s and Ms. Nguyen’s performance
routines. Importantly, during their medication transitions, Mr. Smith
might have included traditional ones such as education, but also pro­
and Ms. Nguyen may not have received any support to manage the
vision of free equipment (testing strips or monitoring devices, safer
changes to their work and the accompanying vulnerabilities. The
over-the-counter products), support from others (e.g., coach, health
changes were not accompanied by additional services or resources that
navigator, or online community), or tools for self-monitoring or medi­
are often provided during transitions of care (e.g., hospital discharge),
cation tasks (Holden et al., 2020a; Mickelson et al., 2015).
such as case management by a social worker, counseling, pharmacy
Although HFE has been applied to traditional transitions of care or
consultation, physical or occupational therapy, financial assistance, or
clinical handovers, there are theoretically many more instances when
education. Nor were the patient’s information needs assessed and
transitions (or changes) occur in the absence of these shifts in the formal
addressed prior or after the change (Attfield et al., 2006). It could even
delivery of care. Like transitions in clinical work, transitions in patient
be said that the clinicians in these cases were not aware of the work that
work can be improved using HFE interventions including workflow
patients would have to do during the transition, or did not recognize the
redesign, team training and standardized communication, tools such as
presence of a meaningful change in the patient’s work, meaning the
checklists and decision aids, and organizational change (Carayon, 2012;
work was invisible (Gorman et al., 2018). Invisibility is akin to clinicians
Carayon et al., 2014). Transitions in patient work may also benefit from
seeing what patients do as idealized work-as-imagined, not
theories and perspectives typically applied by HFE professionals to the
work-as-done in reality, a problem familiar to HFE experts who caution
work of clinicians or other professionals: for example, medication
against conflating the two (Blandford et al., 2014).
transitions, like other work phenomena, can benefit from concepts such
Furthermore, medication transitions, and transitions in patient work
as behavior cueing strategies, organizational routines, error mitigation,
in general, are underpinned by the longitudinal and evolving nature of a
and resilience engineering (Barber, 2002; Furniss et al., 2014; Schubert
patient’s care experience and associated contexts. The quality of this
et al., 2015; Stawarz et al., 2020).
experience, which may be described as the patient journey, is prone to
Given the ongoing and longitudinal care needs of patients, especially
degradation when clinician and healthcare system goals are incongruent
those with chronic conditions, an important contribution of HFE is of­
with and do not fully support patients’ goals (Meyer, 2019).
fering methods and approaches to understand and design for the patient
Table 2 offers a thought exercise about potential interventions for
journey (Jones et al., 2017; Marquez et al., 2015; McCarthy et al., 2016).
patient work transitions that could be inspired by traditional care
Prominent calls have been made to study the patient journey (National
transition programs or their components. For example, at hospital
Academies of Science, Engineering, and Medicine, 2018) and a recent
discharge, several programs assign patients community-based assistance
update to the family of Systems Engineering Initiative for Patient Safety
from an individual specializing in nursing, pharmacy, or medical care. A
(SEIPS) work systems models reflects the emerging patient journey
similar strategy of as-needed, community-based, longitudinal assistance
paradigm (Carayon et al., 2020). Commonly used methods such as
can help patients facing other types of transitions in patient work
process mapping or cognitive task analysis may serve as a foundation for
patient journey mapping but there will likely be a need for adapting
Table 2 existing methods and developing new ones (Holden et al., 2020c). HFE
Traditional interventions for care transitions and potential analogous in­
also offers general approaches such as workload measurement, job
terventions applied to support transitions in patient work.
design, team training, user-centered design, and participatory design,
Traditional care transitions interventions Potential analogous intervention for which can be applied to improving either clinical or patient work
patient work transitions
(Cornet et al., 2020; Novak et al., 2016).
Advanced practice nurse conducts When patient work transition occurs, a Supporting transitions of patient work using HFE complements,
patient needs assessment, develops an professional assesses new needs and rather than replaces, existing attempts to support clinician-focused care
individualized plan of care, and challenges, develops with the patient a
conducts regular follows up (Naylor plan, and provides ongoing monitoring
delivery transitions. Indeed, combining the two approaches may be most
et al., 2004) and support effective, especially when transitions of care (i.e., change in settings or
Monitoring for “red flags,” warning signs Evaluative self-monitoring and outside clinicians) are accompanied by one or more transitions of patient work
of worsening status (Coleman et al., monitoring by others (clinicians, (see Table 1). As an example, consider the transition from childhood to
2006) friends) during and after times of
adulthood among patients with Type I diabetes mellitus (Peters et al.,
change
New role (e.g., community-based Coach, navigator, or peer who is present 2011). This transition involves a change in care delivery from pediatric
paramedic, community health for an extended period during which a to adult care that may benefit from various transition of care in­
workers) created to follow patients patient has undergone or may undergo a terventions (Campbell et al., 2016). It also involves life changes that
from one setting to another (Shah et al., patient work transition require skills training, self-monitoring technology, education on medical
2018) or performing home visits (
Bailey et al., 2016)
insurance and financial management, peer support, new routines, and
Checklists of information to transfer Checklists and summaries of tasks, other types of interventions that target patient work rather than clinical
between settings/clinicians ( information, or resources for a patient to work (Children’s Hospital of Philadelphia, 2019).
Halasyamani et al., 2006), discharge avoid forgetting or confusion
summary documents (Ooi et al., 2017)

4
R.J. Holden and E. Abebe
4. Conclusions
Our message, simply put, is that patients experience transitions due
to changes in their life or sociotechnical systems. Such transitions, as
exemplified by medication transitions involving changes in medications,
are vulnerable periods that may benefit from HFE interventions. HFE
approaches to address transitions in the delivery of care are candidates
for being adapted to also support transitions in the work performance of
patients and other non-professionals.
Funding
This work was supported by grants P30 HS024384-01 (Callahan, PI)
from the Agency for Healthcare Research and Quality (AHRQ) and R01
AG056926-01 (Holden, PI) from the National Institutes of Health (NIH).
The content is solely the responsibility of the authors and does not
necessarily re-present the official views of AHRQ or NIH.
Declaration of competing interest
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influence
the work reported in this paper.
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