An Analysis of Incident Reports Related to Electronic Medication Management: How They Change Over Time.

OBJECTIVE: Electronic medication management (EMM) systems have been shown to introduce new patient safety risks that were not possible, or unlikely to occur, with the use of paper charts. Our aim was to examine the factors that contribute to EMM-related incidents and how these incidents change over time with ongoing EMM use. METHODS: Incidents reported at 3 hospitals between January 1, 2010, and December 31, 2019, were extracted using a keyword search and then screened to identify EMM-related reports. Data contained in EMM-related incident reports were then classified as unsafe acts made by users and the latent conditions contributing to each incident. RESULTS: In our sample, 444 incident reports were determined to be EMM related. Commission errors were the most frequent unsafe act reported by users (n = 298), whereas workarounds were reported in only 13 reports. User latent conditions (n = 207) were described in the highest number of incident reports, followed by conditions related to the organization (n = 200) and EMM design (n = 184). Over time, user unfamiliarity with the system remained a key contributor to reported incidents. Although fewer articles to electronic transfer errors were reported over time, incident reports related to the transfer of information between different computerized systems increased as hospitals adopted more clinical information systems. CONCLUSIONS: Electronic medication management-related incidents continue to occur years after EMM implementation and are driven by design, user, and organizational conditions. Although factors contribute to reported incidents in varying degrees over time, some factors are persistent and highlight the importance of continuously improving the EMM system and its use.

Stakeholder perspectives of system-related errors: Types, contributing factors, and consequences.

BACKGROUND: Despite growing evidence of the benefits of electronic medication management systems (EMMS), research has also identified a range of new safety risks linked with their use. There is limited qualitative research focusing on system-related errors that result from use of EMMS. The aim of this study was to explore in-depth stakeholders' perceptions and experiences of system-related errors. METHODS: Semi-structured interviews were conducted with EMMS users and other relevant staff (e.g. supporting roles in EMMS) across a local health district in Sydney, Australia. Analysis was conducted iteratively using a general inductive approach, and then mapped to Reason's accident causation model, where codes were categorized as 1) unsafe acts (i.e. what error occurred), 2) latent conditions (i.e. what factors contributed to errors), and 3) consequences resulting from the error. RESULTS: Twenty-five participants were interviewed between September 2020 and May 2021. Participants most frequently described omission errors (e.g. failure to check for duplicate orders) as unsafe acts, although commission errors and workarounds were also reported. Poor EMMS design was reported to be a significant workplace factor contributing to system-related errors, however participants also described user factors, such as an overreliance on the system, and organizational factors, such as system downtime, as contributing to errors. Reported consequences of system-related errors included medication errors, but also impacts to the EMMS and on workers. CONCLUSIONS: EMMS design is a significant contributor to system-related errors, but this research showed that user and organizational factors are also at play. As these factors are not independent, minimizing system-related errors requires a multi-faceted approach, where mitigation strategies target not only the EMMS, but also the context in which the system has been implemented.

Comparison of intermittent audit vs daily documentation of pharmacist interventions.

PURPOSE: To compare an intermittent audit method vs a daily documentation method with regard to the number of interventions documented by clinical pharmacists in the hospital setting. METHODS: A 2-phase pre-post cohort study was conducted at an academic hospital to compare numbers and types of pharmacist interventions documented over an 18-month period before implementation of a daily documentation method (the "pre-phase" period) and during the 6 months after implementation (the "post-phase" period). During the pre-phase period (January 2018 to July 2019), pharmacists prospectively documented interventions on specific audit days. The audit days occurred at approximately monthly intervals. During the post-phase period (July 2019 to March 2020) pharmacists used electronic medical record tools to document interventions daily. The primary outcome was the total number of interventions per day. Values for the pre- and post-phase periods were compared using an unpaired Student t test and through interrupted time series analysis. RESULTS: There were a total of 3,628 interventions (on 14 intermittent audit days) during the pre-phase period and 9,300 interventions (on 163 continuous days) in the post-phase period. The mean (SD) number of reported interventions per day decreased from 259 (82) in the pre-phase period to 57 (33) in the post-phase period (P < 0.001). The mean (SD) number of daily reported interventions per pharmacist decreased from 24 (5) in the pre-phase period to 6 (2) in the post-phase period (P < 0.001). This decrease was consistent with results of the interrupted time series analysis. There was a decrease in reported interventions at the time of implementation (change from most recent audit day, -125 interventions; 95% confidence interval [CI], -187 to -62 interventions; P < 0.001). Similarly, there was a decrease in reported interventions per pharmacist at the time of implementation (change from most recent audit day, -22 [95% CI, -26 to -18] interventions; P < 0.001). CONCLUSION: A change from intermittent audits to daily documentation of interventions resulted in an approximately 5-fold decrease in the number of interventions recorded by pharmacists.