Comprehensive Analysis of a Medication Dosing Error Related to CPOE: Table 1
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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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CPOE adoption can generate new kinds of health care-practice related errors.
“Studies have indicated that CPOE adoption can generate new kinds of health care-practice related errors, while others have described roles for CPOE in both preventing and causing medication errors.(4,20 -25 )”
From Types of Unintended Consequences Related to Computerized Provider Order Entry (2006) · cites this paper as [23]
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Patient safety goals for the proposed Federal Health Information Technology Safety Center
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Empowering Patients: Making Health Information and Systems Safer for Patients and the Public
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Chapter 1: Biomedical Knowledge Integration
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Methods for Addressing Technology-induced Errors: The Current State
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Health technology, quality and safety in a learning health system
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Influence of simulation on electronic health record use patterns among pediatric residents
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Safe use of hospital information systems: an evaluation model based on a sociotechnical perspective
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- Authors
- Horsky, J., Kuperman, G. J., & Patel, V. L.
- Affiliations
- NewYork–Presbyterian Hospital (US)
- Corresponding author
- Horsky, Jan
- Venue
- Journal of the American Medical Informatics Association
- Publisher
- Oxford University Press (OUP)
- Published
- 2005-07
- Volume
- 12
- Issue
- 4
- Pages
- 377-382
- ISSN
- 1067-5027 (ISSN-L)
- 1527-974X
- PMC
- PMC1174881
- OpenAlex
- W2167500163
- Cited by
- 197
- References
- 26
- Citations by year
- 2024: 3 · 2023: 7 · 2022: 4 · 2021: 5 · 2020: 5 · 2019: 6 · 2018: 4 · 2017: 12 · 2016: 10 · 2015: 13 · 2014: 13 · 2013: 22 · 2012: 13
- FWCI
- 24.46
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Journal of the American Medical Informatics Association (publishedVersion)
- Europe PMC (PubMed Central) (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- 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 › Family Practice › Clinical Reasoning and Diagnostic Skills
- Keywords
- dosing errors, computerized physician order entry, potassium chloride, human-computer interaction, usability inspection, user training, error propagation
- MeSH terms
- Aged, Hospital Information Systems, Humans, Medication Errors, Medication Systems, Hospital, Clinical Pharmacy Information Systems, Medical Records Systems, Computerized, Organizational Case Studies
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