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: 3.5). 07/2005; 12(4):377-82. DOI: 10.1197/jamia.M1740
Source: DBLP


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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    • "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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    ABSTRACT: Objective To comparatively evaluate the effectiveness of three different methods involving end-users for detecting usability problems in an EHR: user testing, semi-structured interviews and surveys. Materials and methods Data were collected at two major urban dental schools from faculty, residents and dental students to assess the usability of a dental EHR for developing a treatment plan. These included user testing (N = 32), semi-structured interviews (N = 36), and surveys (N = 35). Results The three methods together identified a total of 187 usability violations: 54% via user testing, 28% via the semi-structured interview and 18% from the survey method, with modest overlap. These usability problems were classified into 24 problem themes in 3 broad categories. User testing covered the broadest range of themes (83%), followed by the interview (63%) and survey (29%) methods. Discussion Multiple evaluation methods provide a comprehensive approach to identifying EHR usability challenges and specific problems. The three methods were found to be complementary, and thus each can provide unique insights for software enhancement. Interview and survey methods were found not to be sufficient by themselves, but when used in conjunction with the user testing method, they provided a comprehensive evaluation of the EHR. Conclusion We recommend using a multi-method approach when testing the usability of health information technology because it provides a more comprehensive picture of usability challenges.
    Full-text · Article · May 2014 · International Journal of Medical Informatics
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    • "For vendors the costs arise from re-work by software developers and programmers. For vendors and organizations that have implemented HIT-costs are associated with software fixes, customization fixes, costs of re-implementation, and costs associated with training staff to use the software after the technological fixes have been made [13,23,34]. According to the software engineering literature, costs are logarithmic in nature (i.e., costs increase 10 times as time increases); therefore, the earlier the software issue is identified in the software development lifecycle, the lower the cost of fixing it [48]. "
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    ABSTRACT: Health information technology (HIT) research findings suggested that new healthcare technologies could reduce some types of medical errors while at the same time introducing classes of medical errors (i.e., technology-induced errors). Technology-induced errors have their origins in HIT, and/or HIT contribute to their occurrence. The objective of this paper is to review current trends in the published literature on HIT safety. A review and synthesis of the medical and life sciences literature focusing on the area of technology-induced error was conducted. There were four main trends in the literature on technology-induced error. The following areas were addressed in the literature: definitions of technology-induced errors; models, frameworks and evidence for understanding how technology-induced errors occur; a discussion of monitoring; and methods for preventing and learning about technology-induced errors. The literature focusing on technology-induced errors continues to grow. Research has focused on the defining what an error is, models and frameworks used to understand these new types of errors, monitoring of such errors and methods that can be used to prevent these errors. More research will be needed to better understand and mitigate these types of errors.
    Full-text · Article · Jun 2013 · Healthcare Informatics Research
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    • "Yet, user interfaces for complex software systems also need to have their safety assessed using evidence-based, validated heuristics [1, 12, 23]. This is especially necessary as errors arising from HIS use in healthcare may lead to human harm (i.e., death, disability, or injury) [6, 31, 32], and the costs of fixing the unsafe software are much lower to vendors than the healthcare costs associated with treating individuals who are harmed by the software [14]. "
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    ABSTRACT: Internationally, health information systems (HIS) safety has emerged as a significant concern for governments. Recently, research has emerged that has documented the ability of HIS to be implicated in the harm and death of patients. Researchers have attempted to develop methods that can be used to prevent or reduce technology-induced errors. Some researchers are developing methods that can be employed prior to systems release. These methods include the development of safety heuristics and clinical simulations. In this paper, we outline our methodology for developing safety heuristics specific to identifying the features or functions of a HIS user interface design that may lead to technology-induced errors. We follow this with a description of a methodological approach to validate these heuristics using clinical simulations.
    Full-text · Article · Mar 2013 · Computational and Mathematical Methods in Medicine
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