Stakeholder perspectives of system-related errors: types, contributing factors, and consequences

Madaline Kinlay*, Wu Yi Zheng, Rosemary Burke, Ilona Juraskova, Lai Mun (Rebecca) Ho, Hannah Turton, Jason Trinh, Melissa Baysari

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

4 Citations (Scopus)


Background: Despite growing evidence of the benefits of electronic medication management systems (EMMS), research has also identified a range of new safety risks linked with their use. There is limited qualitative research focusing on system-related errors that result from use of EMMS. The aim of this study was to explore in-depth stakeholders’ perceptions and experiences of system-related errors. Methods: Semi-structured interviews were conducted with EMMS users and other relevant staff (e.g. supporting roles in EMMS) across a local health district in Sydney, Australia. Analysis was conducted iteratively using a general inductive approach, and then mapped to Reason's accident causation model, where codes were categorized as 1) unsafe acts (i.e. what error occurred), 2) latent conditions (i.e. what factors contributed to errors), and 3) consequences resulting from the error. Results: Twenty-five participants were interviewed between September 2020 and May 2021. Participants most frequently described omission errors (e.g. failure to check for duplicate orders) as unsafe acts, although commission errors and workarounds were also reported. Poor EMMS design was reported to be a significant workplace factor contributing to system-related errors, however participants also described user factors, such as an overreliance on the system, and organizational factors, such as system downtime, as contributing to errors. Reported consequences of system-related errors included medication errors, but also impacts to the EMMS and on workers. Conclusions: EMMS design is a significant contributor to system-related errors, but this research showed that user and organizational factors are also at play. As these factors are not independent, minimizing system-related errors requires a multi-faceted approach, where mitigation strategies target not only the EMMS, but also the context in which the system has been implemented.

Original languageEnglish
Article number104821
Pages (from-to)1-7
Number of pages7
JournalInternational Journal of Medical Informatics
Early online date18 Jun 2022
Publication statusPublished - Sept 2022
Externally publishedYes


  • Accident causation model
  • Electronic medication management system
  • Hospital
  • Medication errors
  • Patient safety


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