scholarly journals Prescribing errors in emergency department medication history taking: will electronic medication management systems help?

2019 ◽  
Vol 49 (4) ◽  
pp. 400-402 ◽  
Author(s):  
Susan Welch ◽  
Andrew Finckh
2019 ◽  
Vol 43 (3) ◽  
pp. 276 ◽  
Author(s):  
Melita Van de Vreede ◽  
Anne McGrath ◽  
Jan de Clifford

Objective The aim of the present study was to identify and quantify medication errors reportedly related to electronic medication management systems (eMMS) and those considered likely to occur more frequently with eMMS. This included developing a new classification system relevant to eMMS errors. Methods Eight Victorian hospitals with eMMS participated in a retrospective audit of reported medication incidents from their incident reporting databases between May and July 2014. Site-appointed project officers submitted deidentified incidents they deemed new or likely to occur more frequently due to eMMS, together with the Incident Severity Rating (ISR). The authors reviewed and classified incidents. Results There were 5826 medication-related incidents reported. In total, 93 (47 prescribing errors, 46 administration errors) were identified as new or potentially related to eMMS. Only one ISR2 (moderate) and no ISR1 (severe or death) errors were reported, so harm to patients in this 3-month period was minimal. The most commonly reported error types were ‘human factors’ and ‘unfamiliarity or training’ (70%) and ‘cross-encounter or hybrid system errors’ (22%). Conclusions Although the results suggest that the errors reported were of low severity, organisations must remain vigilant to the risk of new errors and avoid the assumption that eMMS is the panacea to all medication error issues. What is known about the topic? eMMS have been shown to reduce some types of medication errors, but it has been reported that some new medication errors have been identified and some are likely to occur more frequently with eMMS. There are few published Australian studies that have reported on medication error types that are likely to occur more frequently with eMMS in more than one organisation and that include administration and prescribing errors. What does this paper add? This paper includes a new simple classification system for eMMS that is useful and outlines the most commonly reported incident types and can inform organisations and vendors on possible eMMS improvements. The paper suggests a new classification system for eMMS medication errors. What are the implications for practitioners? The results of the present study will highlight to organisations the need for ongoing review of system design, refinement of workflow issues, staff education and training and reporting and monitoring of errors.


2010 ◽  
Vol 18 (1) ◽  
pp. 102-104 ◽  
Author(s):  
Maryann Mazer ◽  
Francis DeRoos ◽  
Judd E. Hollander ◽  
Christine McCusker ◽  
Nicholas Peacock ◽  
...  

2019 ◽  
Vol 49 (2) ◽  
pp. 108-115 ◽  
Author(s):  
Magdalena Z. Raban ◽  
Scott R. Walter ◽  
Lisa G. Pont ◽  
Louis Cheung ◽  
Dana Strumpman ◽  
...  

2013 ◽  
Vol 45 (1) ◽  
pp. 105-110 ◽  
Author(s):  
Michael D. Witting ◽  
Bryan D. Hayes ◽  
Stephen M. Schenkel ◽  
Charles B. Drucker ◽  
Michael P. DeWane ◽  
...  

2021 ◽  
Vol 12 (05) ◽  
pp. 1049-1060
Author(s):  
Madaline Kinlay ◽  
Lai Mun Rebecca Ho ◽  
Wu Yi Zheng ◽  
Rosemary Burke ◽  
Ilona Juraskova ◽  
...  

Abstract 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.


Sign in / Sign up

Export Citation Format

Share Document