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. 2014 Feb;21(e1):e63-70.
doi: 10.1136/amiajnl-2013-001818. Epub 2013 Sep 24.

Classification of medication incidents associated with information technology

Ka-Chun Cheung  1 , Willem van der Veen, Marcel L Bouvy, Michel Wensing, Patricia M L A van den Bemt, Peter A G M de Smet
Affiliations

Classification of medication incidents associated with information technology

Ka-Chun Cheung et al. J Am Med Inform Assoc. 2014 Feb.

Abstract

Introduction: Information technology (IT) plays a pivotal role in improving patient safety, but can also cause new problems for patient safety. This study analyzed the nature and consequences of a large sample of IT-related medication incidents, as reported by healthcare professionals in community pharmacies and hospitals.

Methods: The medication incidents submitted to the Dutch central medication incidents registration (CMR) reporting system were analyzed from the perspective of the healthcare professional with the Magrabi classification. During classification new terms were added, if necessary.

Main measures: The principal source of the IT-related problem, nature of error. Additional measures: consequences of incidents, IT systems, phases of the medication process.

Results: From March 2010 to February 2011 the CMR received 4161 incidents: 1643 (39.5%) from community pharmacies and 2518 (60.5%) from hospitals. Eventually one of six incidents (16.1%, n=668) were related to IT; in community pharmacies more incidents (21.5%, n=351) were related to IT than in hospitals (12.6%, n=317). In community pharmacies 41.0% (n=150) of the incidents were about choosing the wrong medicine. Most of the erroneous exchanges were associated with confusion of medicine names and poor design of screens. In hospitals 55.3% (n=187) of incidents concerned human-machine interaction-related input during the use of computerized prescriber order entry. These use problems were also a major problem in pharmacy information systems outside the hospital.

Conclusions: A large sample of incidents shows that many of the incidents are related to IT, both in community pharmacies and hospitals. The interaction between human and machine plays a pivotal role in IT incidents in both settings.

Keywords: Health information technology; Incidents reporting; Medical informatics; Medication errors; Medication safety; Patient safety.

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Figures

Figure 1
Figure 1
Adapted diagram of Magrabi et al 2012 classification and added terms from central medication incidents registration incidents.
See this image and copyright information in PMC

References

    1. Institute of Medicine, Committee on Quality of Health Care in America Crossing the quality chasm a new health system for the 21st century. Washington, DC: National Academy Press, 2001
    1. Bates DW. Using information technology to reduce rates of medication errors in hospitals. BMJ 2000;320:788–91 - PMC - PubMed
    1. Bates DW, Gawande AA. Improving safety with information technology. N Engl J Med 2003;348:2526–34 - PubMed
    1. van Doormaal JE, van den Bemt PM, Zaal RJ, et al. The influence that electronic prescribing has on medication errors and preventable adverse drug events: an interrupted time-series study. J Am Med Inform Assoc 2009;16:816–25 - PMC - PubMed
    1. Chaudhry B, Wang J, Wu S, et al. Systematic review: impact of health information technology on quality, efficiency, and costs of medical care. Ann Intern Med 2006;144:742–52 - PubMed

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