Medication safety incidents in paediatric oncology after electronic medication management system implementation

Valentina Lichtner, Melissa Baysari, Peter Gates, Luciano Dalla-Pozza, Johanna I. Westbrook

Research output: Contribution to journalArticleResearchpeer-review

Abstract

Objective: To explore medication safety issues related to use of an electronic medication management system (EMM) in paediatric oncology practice, through the analysis of patient safety incident reports. Methods: We analysed 827 voluntarily reported incidents relating to oncology patients that occurred over an 18-month period immediately following implementation of an EMM in a paediatric hospital in Australia. We identified medication-related and EMM-related incidents and carried out a content analysis to identify patterns. Results: We found ~79% (n = 651) of incidents were medication-related and, of these, ~45% (n = 294) were EMM-related. Medication-related incidents included issues with: prescribing; dispensing; administration; patient transfers; missing chemotherapy protocols and information on current stage of patient treatment; coordination of chemotherapy administration; handling or storing medications; children or families handling medications. EMM-related incidents were classified into four groups: technical issues, issues with the user experience, unanticipated problems in EMM workflow, and missing safety features. Conclusions: Incidents reflected difficulties with managing therapies rich in interdependencies. EMM, and especially its ‘automaticity’, contributed to these incidents. As EMM impacts on safety in such high-risk settings, it is essential that users are aware of and attend to EMM automatic behaviours and are equipped to troubleshoot them.

LanguageEnglish
Article numbere13152
Pages1-9
Number of pages9
JournalEuropean Journal of Cancer Care
Volume28
Issue number6
Early online date22 Aug 2019
DOIs
Publication statusPublished - 1 Nov 2019

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Medication Systems
Pediatrics
Safety
Drug Therapy
Patient Transfer
Pediatric Hospitals
Workflow
Patient Safety

Keywords

  • computerized provider order entry system
  • evaluation research
  • hospital oncology services
  • medication errors
  • paediatrics
  • patient safety

Cite this

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abstract = "Objective: To explore medication safety issues related to use of an electronic medication management system (EMM) in paediatric oncology practice, through the analysis of patient safety incident reports. Methods: We analysed 827 voluntarily reported incidents relating to oncology patients that occurred over an 18-month period immediately following implementation of an EMM in a paediatric hospital in Australia. We identified medication-related and EMM-related incidents and carried out a content analysis to identify patterns. Results: We found ~79{\%} (n = 651) of incidents were medication-related and, of these, ~45{\%} (n = 294) were EMM-related. Medication-related incidents included issues with: prescribing; dispensing; administration; patient transfers; missing chemotherapy protocols and information on current stage of patient treatment; coordination of chemotherapy administration; handling or storing medications; children or families handling medications. EMM-related incidents were classified into four groups: technical issues, issues with the user experience, unanticipated problems in EMM workflow, and missing safety features. Conclusions: Incidents reflected difficulties with managing therapies rich in interdependencies. EMM, and especially its ‘automaticity’, contributed to these incidents. As EMM impacts on safety in such high-risk settings, it is essential that users are aware of and attend to EMM automatic behaviours and are equipped to troubleshoot them.",
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Medication safety incidents in paediatric oncology after electronic medication management system implementation. / Lichtner, Valentina; Baysari, Melissa; Gates, Peter; Dalla-Pozza, Luciano; Westbrook, Johanna I.

In: European Journal of Cancer Care, Vol. 28, No. 6, e13152, 01.11.2019, p. 1-9.

Research output: Contribution to journalArticleResearchpeer-review

TY - JOUR

T1 - Medication safety incidents in paediatric oncology after electronic medication management system implementation

AU - Lichtner, Valentina

AU - Baysari, Melissa

AU - Gates, Peter

AU - Dalla-Pozza, Luciano

AU - Westbrook, Johanna I.

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