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Does the implementation of an electronic prescribing system create unintended medication errors? A study of the sociotechnical context through the analysis of reported medication incidents.

Redwood S, Rajakumar A, Hodson J, Coleman JJ - BMC Med Inform Decis Mak (2011)

Bottom Line: Interpretation of results must therefore be tentative.The analysis of sociotechnical incidents by time of day and day of week indicated a trend for increased proportions of these types of incidents occurring on Sundays.Being aware of these types of errors is important to the clinical and technical implementers of such systems in order to, where possible, design out unintended problems, highlight training requirements, and revise clinical practice protocols.

View Article: PubMed Central - HTML - PubMed

Affiliation: University of Birmingham, School of Health and Population Sciences, Birmingham, Edgbaston Campus, B15 2TH, UK. s.redwood@bham.ac.uk

ABSTRACT

Background: Even though electronic prescribing systems are widely advocated as one of the most effective means of improving patient safety, they may also introduce new risks that are not immediately obvious. Through the study of specific incidents related to the processes involved in the administration of medication, we sought to find out if the prescribing system had unintended consequences in creating new errors. The focus of this study was a large acute hospital in the Midlands in the United Kingdom, which implemented a Prescribing, Information and Communication System (PICS).

Methods: This exploratory study was based on a survey of routinely collected medication incidents over five months. Data were independently reviewed by two of the investigators with a clinical pharmacology and nursing background respectively, and grouped into broad types: sociotechnical incidents (related to human interactions with the system) and non-sociotechnical incidents. Sociotechnical incidents were distinguished from the others because they occurred at the point where the system and the professional intersected and would not have occurred in the absence of the system. The day of the week and time of day that an incident occurred were tested using univariable and multivariable analyses. We acknowledge the limitations of conducting analyses of data extracted from incident reports as it is widely recognised that most medication errors are not reported and may contain inaccurate data. Interpretation of results must therefore be tentative.

Results: Out of a total of 485 incidents, a modest 15% (n = 73) were distinguished as sociotechnical issues and thus may be unique to hospitals that have such systems in place. These incidents were further analysed and subdivided into categories in order to identify aspects of the context which gave rise to adverse situations and possible risks to patient safety. The analysis of sociotechnical incidents by time of day and day of week indicated a trend for increased proportions of these types of incidents occurring on Sundays.

Conclusion: Introducing an electronic prescribing system has the potential to give rise to new types of risks to patient safety. Being aware of these types of errors is important to the clinical and technical implementers of such systems in order to, where possible, design out unintended problems, highlight training requirements, and revise clinical practice protocols.

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Frequency of total number of medication administrations and prescriptions for (a) non sociotechnical incidents and (b) sociotechnical incidents.
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Figure 3: Frequency of total number of medication administrations and prescriptions for (a) non sociotechnical incidents and (b) sociotechnical incidents.

Mentions: In addition, the total number of sociotechnical and non-sociotechnical incidents was plotted against the day of the week on which they occurred. The numbers of medication prescriptions and administrations on each day were also plotted to give an indication of how the level of activity fluctuated over the course of the week. Figure 3 shows that compared to the rest of the week, the level of prescribing activity was considerably lower during the weekend. The frequency of non-sociotechnical incidents (Figure 3a) matched this trend, also falling to a lower level during Saturday and Sunday. In contrast, the frequency of sociotechnical incidents (Figure 3b) increased during the weekend, especially on Sunday. This discrepancy between prescribing activity and the frequency of sociotechnical incidents appears to indicate that the increase in the level of sociotechnical incidents on a Sunday may be of interest as it coincides with a reduction in both non-sociotechnical incidents and prescribing activity.


Does the implementation of an electronic prescribing system create unintended medication errors? A study of the sociotechnical context through the analysis of reported medication incidents.

Redwood S, Rajakumar A, Hodson J, Coleman JJ - BMC Med Inform Decis Mak (2011)

Frequency of total number of medication administrations and prescriptions for (a) non sociotechnical incidents and (b) sociotechnical incidents.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3116457&req=5

Figure 3: Frequency of total number of medication administrations and prescriptions for (a) non sociotechnical incidents and (b) sociotechnical incidents.
Mentions: In addition, the total number of sociotechnical and non-sociotechnical incidents was plotted against the day of the week on which they occurred. The numbers of medication prescriptions and administrations on each day were also plotted to give an indication of how the level of activity fluctuated over the course of the week. Figure 3 shows that compared to the rest of the week, the level of prescribing activity was considerably lower during the weekend. The frequency of non-sociotechnical incidents (Figure 3a) matched this trend, also falling to a lower level during Saturday and Sunday. In contrast, the frequency of sociotechnical incidents (Figure 3b) increased during the weekend, especially on Sunday. This discrepancy between prescribing activity and the frequency of sociotechnical incidents appears to indicate that the increase in the level of sociotechnical incidents on a Sunday may be of interest as it coincides with a reduction in both non-sociotechnical incidents and prescribing activity.

Bottom Line: Interpretation of results must therefore be tentative.The analysis of sociotechnical incidents by time of day and day of week indicated a trend for increased proportions of these types of incidents occurring on Sundays.Being aware of these types of errors is important to the clinical and technical implementers of such systems in order to, where possible, design out unintended problems, highlight training requirements, and revise clinical practice protocols.

View Article: PubMed Central - HTML - PubMed

Affiliation: University of Birmingham, School of Health and Population Sciences, Birmingham, Edgbaston Campus, B15 2TH, UK. s.redwood@bham.ac.uk

ABSTRACT

Background: Even though electronic prescribing systems are widely advocated as one of the most effective means of improving patient safety, they may also introduce new risks that are not immediately obvious. Through the study of specific incidents related to the processes involved in the administration of medication, we sought to find out if the prescribing system had unintended consequences in creating new errors. The focus of this study was a large acute hospital in the Midlands in the United Kingdom, which implemented a Prescribing, Information and Communication System (PICS).

Methods: This exploratory study was based on a survey of routinely collected medication incidents over five months. Data were independently reviewed by two of the investigators with a clinical pharmacology and nursing background respectively, and grouped into broad types: sociotechnical incidents (related to human interactions with the system) and non-sociotechnical incidents. Sociotechnical incidents were distinguished from the others because they occurred at the point where the system and the professional intersected and would not have occurred in the absence of the system. The day of the week and time of day that an incident occurred were tested using univariable and multivariable analyses. We acknowledge the limitations of conducting analyses of data extracted from incident reports as it is widely recognised that most medication errors are not reported and may contain inaccurate data. Interpretation of results must therefore be tentative.

Results: Out of a total of 485 incidents, a modest 15% (n = 73) were distinguished as sociotechnical issues and thus may be unique to hospitals that have such systems in place. These incidents were further analysed and subdivided into categories in order to identify aspects of the context which gave rise to adverse situations and possible risks to patient safety. The analysis of sociotechnical incidents by time of day and day of week indicated a trend for increased proportions of these types of incidents occurring on Sundays.

Conclusion: Introducing an electronic prescribing system has the potential to give rise to new types of risks to patient safety. Being aware of these types of errors is important to the clinical and technical implementers of such systems in order to, where possible, design out unintended problems, highlight training requirements, and revise clinical practice protocols.

Show MeSH
Related in: MedlinePlus