Comprehensive Analysis of a Medication Dosing Error Related to CPOE: Table 1

Laboratory of Decision Making and Cognition, Department of Biomedical Informatics, Columbia University, 622 West 168th Street, Vanderbilt Clinic, 5th Floor, New York, NY 10032-3720, USA.
Journal of the American Medical Informatics Association (Impact Factor: 3.93). 07/2005; 12(4):377-82. DOI: 10.1197/jamia.M1740
Source: DBLP

ABSTRACT This case study of a serious medication error demonstrates the necessity of a comprehensive methodology for the analysis of failures in interaction between humans and information systems. The authors used a novel approach to analyze a dosing error related to computer-based ordering of potassium chloride (KCl). The method included a chronological reconstruction of events and their interdependencies from provider order entry usage logs, semistructured interviews with involved clinicians, and interface usability inspection of the ordering system. Information collected from all sources was compared and evaluated to understand how the error evolved and propagated through the system. In this case, the error was the product of faults in interaction among human and system agents that methods limited in scope to their distinct analytical domains would not identify. The authors characterized errors in several converging aspects of the drug ordering process: confusing on-screen laboratory results review, system usability difficulties, user training problems, and suboptimal clinical system safeguards that all contributed to a serious dosing error. The results of the authors' analysis were used to formulate specific recommendations for interface layout and functionality modifications, suggest new user alerts, propose changes to user training, and address error-prone steps of the KCl ordering process to reduce the risk of future medication dosing errors.

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Available from: Vimla L Patel, Aug 21, 2015
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    • "Good usability , the goal of user-centered design [9], is meant to ensure that a technology will empower the user to effectively and efficiently complete work tasks with a high degree of satisfaction and success. Conversely, poor EHR usability has been shown to reduce efficiency, decrease clinician satisfaction, and even compromise patient safety [10] [11] [12] [13] [14] [15] [16] [17] [18] [19]. "
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    • " Inflexible ordering formats causing physicians to generate wrong orders  Absence of automated safeguards in some CPOE implementations  System errors causing duplicate medication orders Henry et al.(2007); Horsky et al.(2005); Koppel et al.(2005); Weiner et al.(1999) "
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    • "Already, the US federal government has committed nearly $20 billion to HIT implementation (Kaushal et al. 2005, US Government, 2010). However, widespread adoption may be limited (Kaushal et al. 2003) owing to unintended outcomes (Baron et al. 2005, Horskey et al. 2005, Pizziferri et al. 2005, Johnson 2006, Ash et al. 2007, de Bont & Bal 2008), uncertainty about benefits and inconsistent randomized controlled trial outcomes (RCT; Raebel et al. 2007, Grant et al. 2008, Schnipper et al. 2009). Additionally, Kaplan and Harris-Salamone (2009) reported that nearly two-thirds of HIT initiatives fail in some aspect, but concluded that most failures have to do with managerial more than technological factors. "
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