A Systematic Review Of The Types And Causes Of Prescribing Errors Generated From Using Computerized Provider Order Entry Systems in Primary and Secondary Care

Objective To understand the different types and causes of prescribing errors associated with computerized provider order entry (CPOE) systems, and recommend improvements in these systems. Materials and Methods We conducted a systematic review of the literature published between January 2004 and June 2015 using three large databases: the Cumulative Index to Nursing and Allied Health Literature, Embase, and Medline. Studies that reported qualitative data about the types and causes of these errors were included. A narrative synthesis of all eligible studies was undertaken. Results A total of 1185 publications were identified, of which 34 were included in the review. We identified 8 key themes associated with CPOE-related prescribing errors: computer screen display, drop-down menus and auto-population, wording, default settings, nonintuitive or inflexible ordering, repeat prescriptions and automated processes, users’ work processes, and clinical decision support systems. Displaying an incomplete list of a patient’s medications on the computer screen often contributed to prescribing errors. Lack of system flexibility resulted in users employing error-prone workarounds, such as the addition of contradictory free-text comments. Users’ misinterpretations of how text was presented in CPOE systems were also linked with the occurrence of prescribing errors. Discussion and Conclusions Human factors design is important to reduce error rates. Drop-down menus should be designed with safeguards to decrease the likelihood of selection errors. Development of more sophisticated clinical decision support, which can perform checks on free-text, may also prevent errors. Further research is needed to ensure that systems minimize error likelihood and meet users’ workflow expectations

An investigation of healthcare professionals’ experiences of training and using electronic prescribing systems: four literature reviews and two qualitative studies undertaken in the UK hospital context

Electronic prescribing (ePrescribing) is the process of ordering medicines electronically for a patient and has been associated with reduced medication errors and improved patient safety. However, these systems have also been associated with unintended adverse consequences. There is a lack of published research about users’ experiences of these systems in UK hospitals. The aim of this research was therefore to firstly describe the literature pertaining to the recent developments and persisting issues with ePrescribing and clinical decision support systems (CDS) (chapter 2). Two further systematic literature reviews (chapters 3 and 4) were then conducted to understand the unintended consequences of ePrescribing and clinical decision support (CDS) systems across both adult and paediatric patients. These revealed a taxonomy of factors, which have contributed to errors during use of these systems e.g., the screen layout, default settings and inappropriate drug-dosage support. The researcher then conducted a qualitative study (chapters 7-10) to explore users’ experiences of using and being trained to use ePrescribing systems. This study involved conducting semi-structured interviews and observations, which revealed key challenges facing users, including issues with using the ‘Medication List’ and how information was presented. Users experienced benefits and challenges when customising the system, including the screen display; however, the process was sometimes overly complex. Users also described the benefits and challenges associated with different forms of interruptive and passive CDS. Order sets, for instance, encouraged more efficient prescribing, yet users often found them difficult to find within the system. A lack of training resulted in users failing to use all features of the ePrescribing system and left some healthcare staff feeling underprepared for using the system in their role. A further literature review (chapter 5) was then performed to complement emerging themes relating to how users were trained to use ePrescribing systems, which were generated as part of a qualitative study. This review revealed the range of approaches used to train users and the need for further research in this area. The literature review and qualitative study-based findings led to a follow-on study (chapter 10), whereby the researcher conducted semi-structured interviews to examine how users were trained to use ePrescribing systems across four NHS Hospital Trusts. A range of approaches were used to train users; tailored training, using clinically specific scenarios or matching the user’s profession to that of the trainer were preferred over lectures and e-learning may offer an efficient way of training large numbers of staff. However, further research is needed to investigate this and whether alternative approaches such as the use of students as trainers could be useful. This programme of work revealed the importance of human factors and user involvement in the design and ongoing development of ePrescribing systems. Training also played a role in users’ experiences of using the system and hospitals should carefully consider the training approaches used. This thesis provides recommendations gathered from the literature and primary data collection that can help inform organisations, system developers and further research in this area

Computerized Physician Order Entry (CPOE) in Reducing Medication Error: A Narrative Review

ABSTRACT Medication error leads to death and injury every day, causing lower quality of life and spend almost 1% of total global health expenditure. One of the solution of to prescribing error is using technology such as Computer Physician Order Entry (CPOE). This study purpose is to assess the use of CPOE in reducing medication error. The research method is a review of the narrative literature using systematic research, with 14 included studies. CPOE systems in hospitals were found to be capable of reducing medication errors especially in prescribing and administrative stage. However, CPOE system can be associated with new types of medication error, therefore, CPOE system must considered human factor, tailored according to the need of the hospital, and continuous training to reduce medication error

Improving Patient Safety and Hospital Service Quality Through Electronic Medical Record: A Systematic Review

ABSTRACT To understand the Electronic medical records (EMR) role in improving patient safety and hospital’s service quality. Articles that included and assessed for the eligibility in this review was an article that show an effect of patient’ safety, and product quality in hospital in correlation on using EMR. The most important function of EMR implementation is to improve patient safety in hospital, in addition to reducing cost. EMR reduce excess cost of Hospital Acquired Condition (HAC) by 16%, reduce death due to HAC by 34%. Doctor and nurse’s belief that the quality of patient data is better when EMR are easier to use and suit with their dialy routine. EMR can improve patient safety, but its use require some skills in technology so it won’t turn to harm patients’ safety. The implementation EMR requires the ability of skilled human resources in using technologies, computer and programs

How do stakeholders experience the adoption of electronic prescribing systems in hospitals? A systematic review and thematic synthesis of qualitative studies

Background: Electronic prescribing (ePrescribing) or computerised provider/physician order entry (CPOE) systems can improve the quality and safety of health services, but the translation of this into reduced harm for patients remains unclear. This review aimed to synthesise primary qualitative research relating to how stakeholders experience the adoption of ePrescribing/CPOE systems in hospitals, to help better understand why and how healthcare organisations have not yet realised the full potential of such systems and to inform future implementations and research. Methods: We systematically searched 10 bibliographic databases and additional sources for citation searching and grey literature, with no restriction on date or publication language. Qualitative studies exploring the perspectives/experiences of stakeholders with the implementation, management, use and/or optimisation of ePrescribing/CPOE systems in hospitals were included. Quality assessment combined criteria from the Critical Appraisal Skills Programme Qualitative Checklist and the Standards for Reporting Qualitative Research guidelines. Data were synthesised thematically. Results: 79 articles were included. Stakeholders’ perspectives reflected a mixed set of positive and negative implications of engaging in ePrescribing/CPOE as part of their work. These were underpinned by further-reaching change processes. Impacts reported were largely practice related rather than at the organisational level. Factors affecting the implementation process and actions undertaken prior to implementation were perceived as important in understanding ePrescribing/CPOE adoption and impact. Conclusions: Implementing organisations and teams should consider the breadth and depth of changes that ePrescribing/CPOE adoption can trigger rather than focus on discrete benefits/problems and favour implementation strategies that: consider the preimplementation context, are responsive to (and transparent about) organisational and stakeholder needs and agendas and which can be sustained effectively over time as implementations develop and gradually transition to routine use and system optimisation

Impact of an inpatient electronic prescribing system on prescribing error causation: a qualitative evaluation in an English hospital

BACKGROUND: Few studies have applied a systems approach to understanding the causes of specific prescribing errors in the context of hospital electronic prescribing (EP). A comprehensive understanding of underlying causes is essential for developing effective interventions to improve prescribing safety. Our objectives were to explore prescribers' perspectives of the causes of errors occurring with EP and to make recommendations to maximise benefits and minimise risks. METHODS: We studied a large hospital using inpatient EP. From April to June 2016, semistructured interviews were conducted with purposively sampled prescribers involved with a prescribing error. Interviews explored prescribers' perceived causes of the error and views about EP; they were audio-recorded and transcribed verbatim. Data were thematically analysed against a framework based on Reason's accident causation model, with a focus on identifying latent conditions. RESULTS: Twenty-five interviews explored causes of 32 errors. Slips and rule-based mistakes were the most common active failures. Error causation was multifactorial; environmental, individual, team, task and technology error-producing conditions were all influenced by EP. There were three broad groups of latent conditions: the EP system's functionality and design; the organisation's decisions around EP implementation and use; and prescribing behaviours in the context of EP. CONCLUSIONS: Errors were associated with the design of EP itself and its integration within the healthcare environment. Findings suggest that EP vendors should focus on revolutionising interface design and usability issues, bearing in mind the wider healthcare context in which such software is used. Healthcare organisations should draw upon human factors principles when implementing EP. Consideration of work environment, infrastructure, training, prescribing responsibilities and behaviours should be considered to address local issues identified

체계적 문헌고찰과 메타분석을 통한 전산처방자동화시스템과 관련된 처방오류 평가 연구

학위논문 (석사) -- 서울대학교 대학원 : 약학대학 약학과, 2020. 8. 김은경.Computerized Physician Order Entry (CPOE) systems and Clinical Decision Support Systems (CDSS) have been proven to contribute to improve patients safety and quality of care; however, the adoption of computerization introduced a new type of error, called system-related or technology-induced errors. A comprehensive evaluation regarding the prevalence of CPOE-related errors (CRE) is lacking. The aim of this study was to describe the prevalence of CRE evaluated by pharmacists and to evaluate the association between the introduction of CPOE and prescribing errors. A systematic review and meta-analysis were conducted of studies retrieved from the MEDLINE, Embase, Cochrane, and Scopus up to March 2020. All studies reporting the rate of prescribing errors related to CPOE were included. The prevalence of CRE among overall prescribing errors occurred in the hospitals was estimated using pooled prevalence estimate with a 95% confidence interval (CI) and relative risk (RR) was calculated for the subgroup analysis. A total of 14 studies were identified and included in the systematic review and meta-analysis. In the meta-analysis of 13 data of estimate, the overall pooled prevalence of CRE across studies were 32.36% (95% CI 22.87 – 42.62). Among the 6 types of error identified throughout the studies: omission, wrong drug, wrong dose, wrong route/form, wrong time, and monitoring error, the main type of error related to CPOE were wrong dose (47.28%, 95% CI 38.38-56.26), followed by wrong drug (14.45%, 95% CI 7.96-22.40). The subgroup analysis revealed that the risk of error was not significantly reduced with CPOE (RR 0.842, 95% CI 0.559 – 1.268), except omission which was significantly reduced after the implementation of CPOE (RR 0.484, 95% CI 0.282 – 0.831). Our study findings support that system-related errors were a major reason for CPOE not delivering a significant reduction in the overall rate of clinical errors. A considerable risk for prescribing errors still exists, which healthcare professionals should be aware that CPOE could also lead to a new type of medication errors. In order to reduce the prescribing error related to CPOE, the system should be continually examined and users should receive periodic and multidisciplinary training on the use of CPOE and CDSS.처방자동화시스템(Computerized Physician Order Entry, CPOE)과 임상의사결정지원시스템(Clinical Decision Support System)의 활성화로 전체적인 처방오류의 비율은 감소하였지만, CPOE와 같은 새로운 시스템으로 인하여 새로운 오류가 출현되었다. 본 연구는 원내 CPOE와 관련된 약물 처방오류 중 약사가 평가한 처방오류의 발생률과 CPOE 도입 전후 오류유형의 변화를 파악하고자 선행연구들을 대상으로 체계적 문헌고찰과 메타분석을 수행하였다. PubMed, EMBASE, Cochrane Register of Controlled Trials, Scopus에서 2020년 3월까지 검색되는 문헌 중 CPOE 도입 후 발생한 처방오류에 해당하는 문헌을 추출하였고 선정 및 제외기준에 따라 총 14개의 최종 문헌을 선정하였다. 처방오류의 합동 발생률 수치와 CPOE 도입 전과 후 유형 별 처방오류 발생의 상대 위험도 및 95% 신뢰 구간은 랜덤 효과 모델을 적용하여 제시하였다. CPOE 도입 후 전체 처방오류 중 CPOE로 인한 처방오류의 발생률 추정치 범위는 12.78%에서 58.54% 사이였고 랜덤 효과 모델에서 계산된 합동 발생률은 32.36%였다 (95% 신뢰 구간 22.87-42.62). National Coordinating Council for Medication Error Reporting and Prevention 분류체계에 기반하여 문헌에서 추출 가능한 처방오류의 유형을 처방 누락오류, 약물 오류, 용량오류, 제형 및 투여경로 오류, 투여 시간 오류, 약물 모니터링과 같이 총 6개 유형으로 분류하였을 때, 용량오류가 47.28% (95% 신뢰 구간 38.38-56.26)로 가장 높았고 그 다음은 약물 오류가 14.45% (95% 신뢰 구간 7.96-22.40)으로 높았다. CPOE 도입 전과 후의 처방오류 유형별 발생을 비교하기 위하여 하위그룹 메타 분석을 하였을 때, CPOE 도입 후 전체적인 처방오류의 발생률은 CPOE 도입 전에 비해 통계적으로 유의하게 증가하지 않았으나 (Relative risk, RR 0.842, 95% 신뢰 구간 0.559-1.168), 6개 처방오류 유형 중 메타분석이 가능한 5개 오류 유형 중 (처방 누락오류, 약물 오류, 용량오류, 제형 및 투여경로 오류, 약물 모니터링) 처방 누락오류만 CPOE 도입 후 유의하게 줄어들었다 (RR 0.484, 95% 신뢰 구간 0.282-0.831). 체계적 문헌고찰 및 메타분석을 통해 새로운 기술인 CPOE 도입 후 CPOE와 관련된 처방오류가 전체 처방오류 중 1/3의 빈도로 발생하는 것으로 파악되었다. 처방오류의 유형 중 처방 누락오류, 약물 오류, 용량오류, 제형 및 투여경로 오류, 약물 모니터링의 오류의 발생 비율은 CPOE 도입 전과 후에 유의한 변화를 보이지 않았으나, 처방 누락의 비율은 CPOE 도입 후에 낮아진 것으로 나타났다. 약물처방의 전자화와 처방 지원 시스템과 같은 새로운 기술의 도입으로 단순 실수로 인한 처방오류는 방지되었으나 다양한 처방오류가 지속해서 발생함으로 환자의 안전을 위한 시스템 사용자의 지속적인 교육과 시스템의 기술적 개선으로 처방오류의 예방, 감지, 및 모니터링의 노력이 필요하다.1. Introduction 1 2. Methods 3 3. Results 8 4. Discussion 25 5. Conclusion 31 References 32 Appendix 40 요약 (국문초록) 48Maste

Safety and Usability Guidelines of Clinical Information Systems Integrating Clinical Workflow: A Systematic Review.

OBJECTIVES: The usability of clinical information systems (CISs) is known to be an essential consideration in ensuring patient safety as well as integrating clinical flow. This study aimed to determine how usability and safety guidelines of CIS consider clinical workflow through a systematic review in terms of the target systems, methodology, and guideline components of relevant articles. METHODS: A literature search was conducted for articles published from 2000 to 2015 in PubMed, Cochrane, EMBASE, Web of Science, and CINAHL. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement method was employed. Articles containing recommendations, principles, and evaluation items for CIS usability and safety were included. The selected articles were classified according to article type, methodology, and target systems. Taking clinical workflow into consideration, the components of guidelines were extracted and classified. RESULTS: A total of 7,401 articles were identified by keyword search. From the 76 articles remaining after abstract screening, 15 were selected through full-text review. Literature review (n = 7) was the most common methodology, followed by expert opinions (n = 6). Computerized physician order entry (n = 6) was the most frequent system. Four articles considered the entire process of clinical tasks, and two articles considered the principles of the entire process of user interface affecting clinical workflow. Only two articles performed heuristic evaluations of CISs. CONCLUSIONS: The usability and safety guidelines of CISs need improvement in guideline development methodology and with consideration of clinical workflow

A systematic literature review on safe health information technology use behaviour

The implementation of health information technology (IT) is one of the strategy to improve patient safety due to medical errors. Nevertheless, inappropriate use of health IT may have serious consequences to the quality of care and patient safety. Most of the previous studies have been focused on the sociotechnical factors contributed to health IT related errors. Little focus has been given on the use behavior that influence the safety of health IT adoption. In order to address this gap, this study investigates the use behavior that influence the safety of health IT adoption. Systematic literature review was conducted to identify articles pertinent to safety of health IT. Science Direct, Medline, EMBASE, and CINAHL database were searched for reviews relevance articles. A total of 23 full articles were reviewed to extract use behavior that influence the safety of health IT adoption. Workarounds, adhere to procedure, vigilant action, and copy and paste behavior were discerned as the significance use behavior that influence health IT safety adoption. This study may be of significance in providing useful information on how to safely practice health IT adoption