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.

Impact of Electronic Medication Management on the Physical Location of Work in a Paediatric Setting.

Electronic medication management (eMM) systems can have a significant impact on efficiency and safety. There is limited evidence on the effects of eMM implementation on the physical location of work. The objective of this study was to evaluate the impact of eMM and associated hardware implementation on the location of tasks performed by doctors and nurses. 41.5 hours of observation were conducted in the oncology ward of a paediatric hospital. Tasks, locations and resources used were recorded pre and post eMM implementation. Results showed that a wider variety of locations were used to conduct tasks following eMM implementation. Post-eMM, more tasks were performed in the hallway, where medication trolleys with attached laptops were situated, and in patient rooms where additional computers were installed, providing more opportunities for patient/carer and clinician interaction. The findings from this study reveal the impact that computer placement has on the location of work for doctors and nurses, and the importance of planning hardware placement for eMM implementation.

Electronic Medication Management Systems: Analysis of Enhancements to Reduce Errors and Improve Workflow.

BACKGROUND: Electronic medication management (eMM) has been shown to reduce medication errors; however, new safety risks have also been introduced that are associated with system use. No research has specifically examined the changes made to eMM systems to mitigate these risks. OBJECTIVES: To (1) identify system-related medication errors or workflow blocks that were the target of eMM system updates, including the types of medications involved, and (2) describe and classify the system enhancements made to target these risks. METHODS: In this retrospective qualitative study, documents detailing updates made from November 2014 to December 2019 to an eMM system were reviewed. Medication-related updates were classified according to "rationale for changes" and "changes made to the system." RESULTS: One hundred and seventeen updates, totaling 147 individual changes, were made to the eMM system over the 4-year period. The most frequent reasons for changes being made to the eMM were to prevent medication errors (24% of reasons), optimize workflow (22%), and support "work as done" on paper (16%). The most frequent changes made to the eMM were options added to lists (14% of all changes), extra information made available on the screen (8%), and the wording or phrasing of text modified (8%). Approximately a third of the updates (37%) related to high-risk medications. The reasons for system changes appeared to vary over time, as eMM functionality and use expanded. CONCLUSION: To our knowledge, this is the first study to systematically review and categorize system updates made to overcome new safety risks associated with eMM use. Optimization of eMM is an ongoing process, which changes over time as users become more familiar with the system and use is expanded to more sites. Continuous monitoring of the system is necessary to detect areas for improvement and capitalize on the benefits an electronic system can provide.

Co-designing a dashboard of predictive analytics and decision support to drive care quality and client outcomes in aged care: a mixed-method study protocol.

INTRODUCTION: There is a clear need for improved care quality and quality monitoring in aged care. Aged care providers collect an abundance of data, yet rarely are these data integrated and transformed in real-time into actionable information to support evidence-based care, nor are they shared with older people and informal caregivers. This protocol describes the co-design and testing of a dashboard in residential aged care facilities (nursing or care homes) and community-based aged care settings (formal care provided at home or in the community). The dashboard will comprise integrated data to provide an 'at-a-glance' overview of aged care clients, indicators to identify clients at risk of fall-related hospitalisations and poor quality of life, and evidence-based decision support to minimise these risks. Longer term plans for dashboard implementation and evaluation are also outlined. METHODS: This mixed-method study will involve (1) co-designing dashboard features with aged care staff, clients, informal caregivers and general practitioners (GPs), (2) integrating aged care data silos and developing risk models, and (3) testing dashboard prototypes with users. The dashboard features will be informed by direct observations of routine work, interviews, focus groups and co-design groups with users, and a community forum. Multivariable discrete time survival models will be used to develop risk indicators, using predictors from linked historical aged care and hospital data. Dashboard prototype testing will comprise interviews, focus groups and walk-through scenarios using a think-aloud approach with staff members, clients and informal caregivers, and a GP workshop. ETHICS AND DISSEMINATION: This study has received ethical approval from the New South Wales (NSW) Population & Health Services Research Ethics Committee and Macquarie University's Human Research Ethics Committee. The research findings will be presented to the aged care provider who will share results with staff members, clients, residents and informal caregivers. Findings will be disseminated as peer-reviewed journal articles, policy briefs and conference presentations.

A Tool for Evaluating Medication Alerting Systems: Development and Initial Assessment.

BACKGROUND: It is well known that recommendations from electronic medication alerts are seldom accepted or acted on by users. Key factors affecting the effectiveness of medication alerts include system usability and alert design. Thus, human factors principles that apply knowledge of human capabilities and limitations are increasingly used in the design of health technology to improve the usability of systems. OBJECTIVE: This study aims to evaluate a newly developed evidence-based self-assessment tool that allows the valid and reliable evaluation of computerized medication alerting systems. This tool was developed to be used by hospital staff with detailed knowledge of their hospital's computerized provider order entry system and alerts to identify and address potential system deficiencies. In this initial assessment, we aim to determine whether the items in the tool can measure compliance of medication alerting systems with human factors principles of design, the tool can be consistently used by multiple users to assess the same system, and the items are easy to understand and perceived to be useful for assessing medication alerting systems. METHODS: The Tool for Evaluating Medication Alerting Systems (TEMAS) was developed based on human factors design principles and consisted of 66 items. In total, 18 staff members recruited across 6 hospitals used the TEMAS to assess their medication alerting systems. Data collected from participant assessments were used to evaluate the validity, reliability, and usability of the TEMAS. Validity was assessed by comparing the results of the TEMAS with those of prior in-house evaluations. Reliability was measured using Krippendorff α to determine agreement among assessors. A 7-item survey was used to determine usability. RESULTS: The participants reported mostly negative (n=8) and neutral (n=7) perceptions of alerts in their medication alerting system. However, the validity of the TEMAS could not be directly tested, as participants were unaware of any results from prior in-house evaluations. The reliability of the TEMAS, as measured by Krippendorff α, was low to moderate (range 0.26-0.46); however, participant feedback suggests that individuals' knowledge of the system varied according to their professional background. In terms of usability, 61% (11/18) of participants reported that the TEMAS items were generally easy to understand; however, participants suggested the revision of 22 items to improve clarity. CONCLUSIONS: This initial assessment of the TEMAS allowed the identification of its components that required modification to improve usability and usefulness. It also revealed that for the TEMAS to be effective in facilitating a comprehensive assessment of a medication alerting system, it should be completed by a multidisciplinary team of hospital staff from both clinical and technical backgrounds to maximize their knowledge of systems.

The impact of introducing automated dispensing cabinets, barcode medication administration, and closed-loop electronic medication management systems on work processes and safety of controlled medications in hospitals: A systematic review.

BACKGROUND: Technology in the form of Automated Dispensing Cabinets (ADCs), Barcode Medication Administration (BCMA), and closed-loop Electronic Medication Management Systems (EMMS) are implemented in hospitals to assist with the supply, use and monitoring of medications. Although there is evidence to suggest that these technologies can reduce errors and improve monitoring of medications in general, little is known about their impact on controlled medications such as opioids. OBJECTIVES: This review aimed to fill this knowledge gap by synthesising literature to determine the impact of ADCs, BCMA and closed-loop EMMS on clinical work processes, medication safety, and drug diversion associated with controlled medications in the inpatient setting. METHODS: Eight databases (Medline, Pubmed, Embase, Scopus, Web of Science, PsycINFO, CINAHL, and ScienceDirect) were searched for relevant papers published between January 2000 and May 2019. Qualitative, quantitative, and mixed-methods empirical studies published in English that reported findings on the impact of ADCs, BCMA and/or closed-loop EMMS on controlled medications in the inpatient setting were included. RESULTS: In total, 16 papers met the inclusion criteria. Eleven studies reported on ADCs, four on BCMA, and only one on closed-loop EMMS. Only four studies focused on controlled medications, with the remainder reporting only incidental findings. Studies reported the elimination of manual end-of-shift counts of controlled medications after ADC implementation but cases of drug diversion were reported despite introducing ADCs. Three quantitative studies reported reductions in medication errors after implementing BCMA, but medications labelled with wrong barcodes and unreadable barcodes led to confusion and administration errors. CONCLUSIONS: More quality, targeted research is needed to provide evidence on the benefits and also risks of implementing technology to safeguard against inappropriate use of controlled medications in the inpatient setting. Processes need to be in place to supplement technological capabilities, and resources should be made available for post-implementation evaluations and interventions.

Do user preferences align with human factors assessment scores of drug-drug interaction alerts?

This study aimed to assess drug-drug interaction alert interfaces and to examine the relationship between compliance with human factors principles and user-preferences of alerts. Three reviewers independently evaluated drug-drug interaction alert interfaces in seven electronic systems using the Instrument-for-Evaluating-Human-Factors-Principles-in-Medication-Related-Decision-Support-Alerts (I-MeDeSA). Fifty-three doctors and pharmacists completed a survey to rate the alert interfaces from best to worst and reported on liked and disliked features. Human factors compliance and user-preferences of alerts were compared. Statistical analysis revealed no significant association between I-MeDeSA scores and user-preferences. However, the strengths and weaknesses of drug-drug interaction alerts from users' perspectives were in-line with the human factors constructs evaluated by the I-MeDeSA. I-MeDeSA in its current form, is unable to identify alerts that are preferred by the users. The design principles assessed by I-MeDeSA appear to be sound, but its arbitrary allocation of points to each human factors construct may not reflect the relative importance that the end-users place on different aspects of alert design.