Conducting an efficient proactive risk assessment prior to CPOE implementation in an intensive care unit
Open accessAbstract
Purpose To develop, conduct, and evaluate a proactive risk assessment (PRA) of the design and implementation of CPOE in an ICU.Methods We developed a PRA method based on issues identified from documented experience with conventional PRA methods and the constraints of an organization about to implement CPOE in an intensive care unit. The PRA method consists of three phases: planning (three months), team (one five-hour meeting), and evaluation (short- and long-term).Results Sixteen unique relevant vulnerabilities were identified as a result of the PRA team's efforts. Negative consequences resulting from the vulnerabilities included potential patient safety and quality of care issues, non-compliance with regulatory requirements, increases in cognitive burden on CPOE users, and/or worker inconvenience or distress. Actions taken to address the vulnerabilities included redesign of the technology, process (workflow) redesign, user training, and/or ongoing monitoring. Verbal and written evaluation by the team members indicated that the PRA method was useful and that participants were willing to participate in future PRAs. Long-term evaluation was accomplished by monitoring an ongoing "issues list" of CPOE problems identified by or reported to IT staff. Vulnerabilities identified by the team were either resolved prior to CPOE implementation (n=7) or shortly thereafter (n=9). No other issues were identified beside those identified by the team.Conclusions Generally positive results from the various evaluations including a long-term evaluation demonstrate the value of developing an efficient PRA method that meets organizational and contextual requirements and constraints.
The claims and statistics of this paper haven’t been checked yet.
Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.
Integrity signals
Registry
Cites
Statistics
Claims the paper makes
The claims and statistics of this paper haven’t been checked yet.
Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
Emerging evidence suggests that health information technology may cause new patient safety concerns and other unintended consequences due to usability issues, disruptions of clinical processes, and unsafe workarounds.
“However, emerging evidence suggests that HIT may cause new patient safety concerns and other unintended consequences due to usability issues, disruptions of clinical processes, and unsafe workarounds to circumvent technology-related constraints.2–16”
From An analysis of electronic health record-related patient safety concerns (2014) · cites this paper as [7]
Technology can introduce new uncertainties and patient safety risks by disrupting established work patterns, creating new risks in practice, and encouraging workarounds.
“research suggests that technology may lead to new uncertainties and risks for patient safety through disrupting established work patterns, creating new risks in practice, and encouraging workarounds.”
From Exploring the sociotechnical intersection of patient safety and electronic health record implementation (2014) · cites this paper as [7]
Self-check
Percentages, sums and reported differences re-computed from the paper’s own numbers.
The self-check needs the paper’s full text.
Cites
Sample size in qualitative research
Sandelowski, M. (1995) · Research in Nursing & Health · doi:10.1002/nur.4770180211 · Cited by 4,372 · see citing works
Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors
Koppel, R. (2005) · JAMA · doi:10.1001/jama.293.10.1197 · Cited by 2,126 · see citing works
Work system design for patient safety: the SEIPS model
Carayon, P., Schoofs Hundt, A., Karsh, B.-T., Gurses, A. P., Alvarado, C. J., Smith, M., & Flatley Brennan, P. (2006) · Quality in Health Care · doi:10.1136/qshc.2005.015842 · Cited by 1,795 · cited 1× · see citing works
“Many of these vulnerabilities occur by not considering the work system in which the technology is implemented and are related to the design of the technology and its impact on workflows and processes [5].”
BackgroundSelf-citationAsh, J. S. (2003) · Journal of the American Medical Informatics Association · doi:10.1197/jamia.m1471 · Cited by 1,789 · see citing works
Beyond usability: Designing effective technology implementation systems to promote patient safety
Karsh, B.-T. (2004) · Quality and Safety in Health Care · doi:10.1136/qshc.2004.010322 · Cited by 414 · see citing works
Categorizing the unintended sociotechnical consequences of computerized provider order entry
Ash, J. S., Sittig, D. F., Dykstra, R. H., Guappone, K., Carpenter, J. D., & Seshadri, V. (2007) · International Journal of Medical Informatics · doi:10.1016/j.ijmedinf.2006.05.017 · Cited by 267 · see citing works
Comprehensive Analysis of a Medication Dosing Error Related to CPOE: Table 1
Horsky, J., Kuperman, G. J., & Patel, V. L. (2005) · Journal of the American Medical Informatics Association · doi:10.1197/jamia.m1740 · Cited by 197 · see citing works
Using failure mode and effects analysis to plan implementation of smart i.v. pump technology
Wetterneck, T. B., Skibinski, K. A., Roberts, T. L., Kleppin, S. M., Schroeder, M. E., Enloe, M., Rough, S. S., Hundt, A. S., & Carayon, P. (2006) · American Journal of Health-System Pharmacy · doi:10.2146/ajhp050515 · Cited by 134 · see citing works
Self-citationBonnabry, P., Despont-Gros, C., Grauser, D., Casez, P., Despond, M., Pugin, D., Rivara-Mangeat, C., Koch, M., Vial, M., Iten, A., et al. (2008) · Journal of the American Medical Informatics Association · doi:10.1197/jamia.m2677 · Cited by 111 · see citing works
A Systematic Quantitative Assessment of Risks Associated With Poor Communication in Surgical Care
Nagpal, K. (2010) · Archives of Surgery · doi:10.1001/archsurg.2010.105 · Cited by 100 · see citing works
Ashley, L., Armitage, G., Neary, M., et al. (2010) · The Joint Commission Journal on Quality and Patient Safety · doi:10.1016/s1553-7250(10)36053-3 · Cited by 99 · see citing works
Challenges to inter-departmental coordination of patient transfers: A workflow perspective
Abraham, J., & Reddy, M. C. (2009) · International Journal of Medical Informatics · doi:10.1016/j.ijmedinf.2009.11.001 · Cited by 91 · see citing works
Habraken, M., van der Schaaf, T., JONGE, J. D., & Rutte, C. G. (2010) · Social Science & Medicine · doi:10.1016/j.socscimed.2010.01.006 · Cited by 56 · see citing works
Lyons, M. (2008) · Applied Ergonomics · doi:10.1016/j.apergo.2008.11.004 · Cited by 56 · see citing works
Faye, H., Rivera-Rodriguez, A. J., Karsh, B., Hundt, A. S., Baker, C., & Carayon, P. (2010) · The Joint Commission Journal on Quality and Patient Safety · doi:10.1016/s1553-7250(10)36056-9 · Cited by 43 · see citing works
Self-citationOrganisational failures in urgent and emergency surgeryA potential peri‐operative risk factor
Pearse, R. M., Dana, E. C., Lanigan, C., & Pook, J. A. R. (2001) · Anaesthesia · doi:10.1046/j.1365-2044.2001.01374-4.x · Cited by 32 · see citing works
Tubing Misload Allows Free Flow Event with Smart Intravenous Infusion Pump
Schroeder, M. E., Wolman, R. L., Wetterneck, T. B., et al. (2006) · Anesthesiology · doi:10.1097/00000542-200608000-00038 · Cited by 13 · see citing works
Self-citationLessons learned while building an integrated ICU workstation
Friesdorf, W., Groß-Alltag, F., Konichezky, S., et al. (1994) · International journal of clinical monitoring and computing · doi:10.1007/bf01259558 · Cited by 11 · see citing works
Flagged first, then by citations
Research works printed but not linked: 6
- [9]Carayon P Faye H Hundt AS Karsh B-T Wetterneck TB Yuehwern Y Patient safety and proactive risk assessment Handbook of Healthcare Delivery Systems 2010 Taylor & Francis
- [19]Wetterneck TB Skibinski K Schroeder M Roberts TL Carayon P Challenges with the performance of failure mode and effects analysis in healthcare organizations: An IV medication administration HFMEATM 2004 Annual Conference of the Human Factors and Ergonomics Society; 2004 September 20–24, 2004 New Orleans, LA The Human Factors and Ergonomics Society
- [20]Wetterneck TB Hundt AS Carayon P FMEA team performance in health care: A qualitative analysis of team member perceptions Journal of Patient Safety 2009 5 2 102 108 19920449
- [22]Walker JM Bieber EJ Richards F Implementing an Electronic Health Record System 2005 London Springer-Verlag
- [27]Stead WW Lin HS Computational Technology for Effective Health Care 2009 Washington DC The National Academies Press 20662117
- [28]Davis S Riley W Gurses AP Miller K Hansen H Henriksen K Battles JB Keyes MA Failure modes and effects analysis based on in situ simulations: A methodology to improve understanding of risks and failures Advances in Patient Safety: New Directions and Alternative Approaches 2008 Rockville, MD Agency for Healthcare Research and Quality 21249922
Cited by
Sorted by citations
Holden, R. J., Carayon, P., Gurses, A. P., Hoonakker, P., Hundt, A. S., Ozok, A. A., & Rivera-Rodriguez, A. J. (2013) · Ergonomics · doi:10.1080/00140139.2013.838643 · Cited by 1,221 · see citing works
Self-citationAn analysis of electronic health record-related patient safety concerns
Meeks, D. W., Smith, M. W., Taylor, L., Sittig, D. F., Scott, J. M., & Singh, H. (2014) · Journal of the American Medical Informatics Association · doi:10.1136/amiajnl-2013-002578 · Cited by 207 · see citing works
Meeks, D. W., Takian, A., Sittig, D. F., Singh, H., & Barber, N. (2014) · Journal of the American Medical Informatics Association · doi:10.1136/amiajnl-2013-001762 · Cited by 91 · see citing works
Resilient practices in maintaining safety of health information technologies
Smith, M. W., Ash, J. S., Sittig, D. F., & Singh, H. (2014) · Journal of Cognitive Engineering and Decision Making · doi:10.1177/1555343414534242 · Cited by 26 · see citing works
- Authors
- Hundt, A. S., Adams, J. A., Schmid, J. A., Musser, L. M., Walker, J. M., Wetterneck, T. B., Douglas, S. V., Paris, B. L., & Carayon, P.
- Affiliations
- University of Wisconsin–Madison (US)
- Geisinger Health System (US)
- Corresponding author
- Hundt, Ann Schoofs
- ORCID
- Carayon, Pascale
- Venue
- International Journal of Medical Informatics
- Publisher
- Elsevier BV
- Published
- 2013-01
- Volume
- 82
- Issue
- 1
- Pages
- 25-38
- ISSN
- 1386-5056 (ISSN-L)
- PMC
- PMC3430828
- OpenAlex
- W2100736211
- Cited by
- 40
- References
- 18
- Citations by year
- 2026: 1 · 2025: 2 · 2024: 1 · 2023: 4 · 2022: 3 · 2021: 4 · 2020: 1 · 2019: 1 · 2018: 2 · 2017: 1 · 2016: 4 · 2015: 3 · 2014: 6 · 2013: 6 · 2012: 1
- FWCI
- 8.30
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- International Journal of Medical Informatics (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- Funders
- Georgia Clinical and Translational Science Alliance
- National Institutes of Health (UL1TR000427)
- Agency for Healthcare Research and Quality (R01 HS015274, R01 HS15274)
- National Center for Research Resources (UL1RR025011)
- National Center for Advancing Translational Sciences (9U54 TR000021)
- Topics
- Health Sciences › Health Professions › Health Information Management › Electronic Health Records Systems
- Health Sciences › Health Professions › Emergency Medical Services › Patient Safety and Medication Errors
- Health Sciences › Medicine › Surgery › Healthcare Technology and Patient Monitoring
- Keywords
- proactive risk assessment, computerized physician order entry, CPOE implementation, intensive care unit, patient safety, vulnerability detection, workflow redesign, cognitive burden, regulatory compliance, user training
- MeSH terms
- Evaluation Studies as Topic, Humans, Intensive Care Units, Risk Assessment, Medical Errors, Guideline Adherence, Medical Order Entry Systems
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
Are you an author, or do you see a problem with this page? Request a review
