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.
| Language | English |
|---|---|
| Article number | e13152 |
| Pages | 1-9 |
| Number of pages | 9 |
| Journal | European Journal of Cancer Care |
| Volume | 28 |
| Issue number | 6 |
| Early online date | 22 Aug 2019 |
| DOIs | |
| Publication status | Published - 1 Nov 2019 |
Fingerprint
Keywords
- computerized provider order entry system
- evaluation research
- hospital oncology services
- medication errors
- paediatrics
- patient safety
Cite this
}
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 journal › Article › Research › peer-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.
PY - 2019/11/1
Y1 - 2019/11/1
N2 - 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.
AB - 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.
KW - computerized provider order entry system
KW - evaluation research
KW - hospital oncology services
KW - medication errors
KW - paediatrics
KW - patient safety
UR - http://www.scopus.com/inward/record.url?scp=85070904153&partnerID=8YFLogxK
UR - http://purl.org/au-research/grants/nhmrc/1094878
U2 - 10.1111/ecc.13152
DO - 10.1111/ecc.13152
M3 - Article
VL - 28
SP - 1
EP - 9
JO - European Journal of Cancer Care
T2 - European Journal of Cancer Care
JF - European Journal of Cancer Care
SN - 1365-2354
IS - 6
M1 - e13152
ER -