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

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

*Corresponding author for this work

Research output: Contribution to journalArticle

1 Citation (Scopus)


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.

Original languageEnglish
Article numbere13152
Pages (from-to)1-9
Number of pages9
JournalEuropean Journal of Cancer Care
Issue number6
Early online date22 Aug 2019
Publication statusPublished - 1 Nov 2019


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

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    Westbrook, J., Georgiou, A., Day, R., O'Brien, T., Karnon, J., Dalla-Pozza, L., Cowell, P., Li, L., Baysari, M., Ambler, G., PhD Contribution (NHMRC), P. C. (. & PhD Contribution 2 (NHMRC), P. C. 2. (.

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