Nurses' medication administration workarounds when using electronic systems: an analysis of safety incident reports

Hannah I. Roberts; Madaline Kinlay; Deborah Debono; Rosemary Burke; Aaron Jones; Melissa T. Baysari

doi:10.3233/SHTI230369

Nurses' medication administration workarounds when using electronic systems: an analysis of safety incident reports

Hannah I. Roberts, Madaline Kinlay, Deborah Debono, Rosemary Burke, Aaron Jones, Melissa T. Baysari

Research output: Chapter in Book/Report/Conference proceeding › Conference proceeding contribution › peer-review

4 Citations (Scopus)

23 Downloads (Pure)

Abstract

Electronic medication management systems (EMMS) have been implemented in most acute care settings in Australia to reduce medication error rates. One of the key challenges related to the introduction of EMMS in hospitals is the uptake of informal "workarounds" by clinicians, including nurses. In this study, we aimed to examine one workaround in depth, nurses not documenting medication administration in the EMMS at the time of administration. We conducted a review of incident reports to identify the factors that contribute to this workaround occurring and the consequences or potential consequences of this workaround on patients. We identified a range of contributing factors, with factors relating to the user (e.g. nurses being time poor) occurring most frequently in incident reports. The most frequently seen consequence of this workaround was the patient receiving an additional dose. This research revealed that strategies to reduce the uptake of this workaround should consider user and organisational factors rather than just EMMS design alone.

Original language	English
Title of host publication	Context Sensitive Health Informatics and the Pandemic Boost
Subtitle of host publication	All Systems Go!
Editors	Adeola Bamgboje-Ayodele, Mirela Prgomet, Craig E. Kuziemsky, Peter Elkin, Christian Nøhr
Place of Publication	Amsterdam
Publisher	IOS Press
Pages	57-61
Number of pages	5
Volume	304
ISBN (Electronic)	9781643683997
ISBN (Print)	9781643683980
DOIs	https://doi.org/10.3233/SHTI230369
Publication status	Published - 22 Jun 2023
Externally published	Yes
Event	Context Sensitive Health Informatics Conference - The University of Sydney, Sydney, Australia Duration: 5 Jul 2023 → 6 Jul 2023 https://www.cshi-imia.org/

Publication series

Name	Studies in Health Technology and Informatics
Publisher	IOS Press
Volume	304
ISSN (Print)	0926-9630
ISSN (Electronic)	1879-8365

Conference

Conference	Context Sensitive Health Informatics Conference
Abbreviated title	CSHI 2023
Country/Territory	Australia
City	Sydney
Period	5/07/23 → 6/07/23
Internet address	https://www.cshi-imia.org/

Bibliographical note

Copyright the Author(s) and IOS Press 2023. Version archived for private and non-commercial use with the permission of the author/s and according to publisher conditions. For further rights please contact the publisher.

Keywords

electronic medication management systems
incident reports
nurse
workaround

Access to Document

10.3233/SHTI230369Licence: CC BY-NC

Publisher version (open access)Final published version, 199 KBLicence: CC BY-NC

Cite this

Roberts, H. I., Kinlay, M., Debono, D., Burke, R., Jones, A., & Baysari, M. T. (2023). Nurses' medication administration workarounds when using electronic systems: an analysis of safety incident reports. In A. Bamgboje-Ayodele, M. Prgomet, C. E. Kuziemsky, P. Elkin, & C. Nøhr (Eds.), Context Sensitive Health Informatics and the Pandemic Boost: All Systems Go! (Vol. 304, pp. 57-61). (Studies in Health Technology and Informatics; Vol. 304). IOS Press. https://doi.org/10.3233/SHTI230369

Roberts, Hannah I. ; Kinlay, Madaline ; Debono, Deborah et al. / Nurses' medication administration workarounds when using electronic systems : an analysis of safety incident reports. Context Sensitive Health Informatics and the Pandemic Boost: All Systems Go!. editor / Adeola Bamgboje-Ayodele ; Mirela Prgomet ; Craig E. Kuziemsky ; Peter Elkin ; Christian Nøhr. Vol. 304 Amsterdam : IOS Press, 2023. pp. 57-61 (Studies in Health Technology and Informatics).

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Roberts, HI, Kinlay, M, Debono, D, Burke, R, Jones, A & Baysari, MT 2023, Nurses' medication administration workarounds when using electronic systems: an analysis of safety incident reports. in A Bamgboje-Ayodele, M Prgomet, CE Kuziemsky, P Elkin & C Nøhr (eds), Context Sensitive Health Informatics and the Pandemic Boost: All Systems Go!. vol. 304, Studies in Health Technology and Informatics, vol. 304, IOS Press, Amsterdam, pp. 57-61, Context Sensitive Health Informatics Conference, Sydney, Australia, 5/07/23. https://doi.org/10.3233/SHTI230369

Nurses' medication administration workarounds when using electronic systems: an analysis of safety incident reports. / Roberts, Hannah I.; Kinlay, Madaline; Debono, Deborah et al.
Context Sensitive Health Informatics and the Pandemic Boost: All Systems Go!. ed. / Adeola Bamgboje-Ayodele; Mirela Prgomet; Craig E. Kuziemsky; Peter Elkin; Christian Nøhr. Vol. 304 Amsterdam: IOS Press, 2023. p. 57-61 (Studies in Health Technology and Informatics; Vol. 304).

Research output: Chapter in Book/Report/Conference proceeding › Conference proceeding contribution › peer-review

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AU - Kinlay, Madaline

AU - Debono, Deborah

AU - Burke, Rosemary

AU - Jones, Aaron

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N1 - Copyright the Author(s) and IOS Press 2023. Version archived for private and non-commercial use with the permission of the author/s and according to publisher conditions. For further rights please contact the publisher.

PY - 2023/6/22

Y1 - 2023/6/22

N2 - Electronic medication management systems (EMMS) have been implemented in most acute care settings in Australia to reduce medication error rates. One of the key challenges related to the introduction of EMMS in hospitals is the uptake of informal "workarounds" by clinicians, including nurses. In this study, we aimed to examine one workaround in depth, nurses not documenting medication administration in the EMMS at the time of administration. We conducted a review of incident reports to identify the factors that contribute to this workaround occurring and the consequences or potential consequences of this workaround on patients. We identified a range of contributing factors, with factors relating to the user (e.g. nurses being time poor) occurring most frequently in incident reports. The most frequently seen consequence of this workaround was the patient receiving an additional dose. This research revealed that strategies to reduce the uptake of this workaround should consider user and organisational factors rather than just EMMS design alone.

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Roberts HI, Kinlay M, Debono D, Burke R, Jones A, Baysari MT. Nurses' medication administration workarounds when using electronic systems: an analysis of safety incident reports. In Bamgboje-Ayodele A, Prgomet M, Kuziemsky CE, Elkin P, Nøhr C, editors, Context Sensitive Health Informatics and the Pandemic Boost: All Systems Go!. Vol. 304. Amsterdam: IOS Press. 2023. p. 57-61. (Studies in Health Technology and Informatics). doi: 10.3233/SHTI230369

Nurses' medication administration workarounds when using electronic systems: an analysis of safety incident reports

Abstract

Publication series

Conference

Bibliographical note

Keywords

Access to Document

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