Identifying Health Information Technology Usability Issues Contributing to Medication Errors Across Medication Process Stages
Identifying Health Information Technology Usability Issues Contributing to Medication Errors Across Medication Process Stages
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DOI：
10.1097/pts.0000000000000868
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发表时间：
2021-12-01
影响因子：
2.2
通讯作者：
Ratwani, Raj M.
中科院分区：
文献类型：
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作者：
Adams, Katharine T.;Pruitt, Zoe;Ratwani, Raj M.
目的不同的卫生信息技术（卫生IT）系统旨在支持药物订购，审查和管理。我们试图确定与医疗IT使用相关的用药错误类型，它们是否到达患者，在用药过程中发生这些错误的位置，以及导致这些错误的特定可用性问题。方法分析了2013年1月至2018年9月期间超过595家医疗机构的患者安全事件报告。我们通过计算识别与医疗IT相关的报告，旨在支持用药流程，包括计算机化的供应商订单输入、电子给药记录和条形码给药。其中，手动审查了2700份报告，以确定用药错误类型、用药过程阶段和健康IT可用性问题。结果在2700份手动审查的报告中，1508份（55.9%）描述了与医疗IT使用相关的用药错误，750份（49.7%）到达患者。剂量错误频繁发生（1214/1508，80.5%），大多数错误发生在订购（673/1508，44.6%）和审查药物（639/1508，42.4%）期间。大多数医疗IT相关用药错误报告描述了可用性问题（n = 1468/1508，97.3%），包括数据输入、工作流支持和警报。数据输入可用性问题影响了几个药物处理阶段，而工作流支持和警报影响了几个阶段。结论：医疗IT可用性问题是导致用药错误的一个普遍因素，其中许多错误会影响到患者。在可用性和安全性优化工作中，应优先考虑数据输入、工作流支持和警报。
Objective Different health information technology (health IT) systems are intended to support medication ordering, reviewing, and administration. We sought to identify the types of medication errors associated with health IT use, whether they reached the patient, where in the medication process those errors occurred, and the specific usability issues contributing to those errors. Methods Patient safety event reports from more than 595 healthcare facilities entered between January 2013 and September 2018 were analyzed. We computationally identified reports associated with health IT intended to support the medication process, including computerized provider order entry, electronic medication administration record, and barcode medication administration. From these, 2700 reports were manually reviewed to determine the type of medication error, medication process stage, and health IT usability issue. Results Of the 2700 manually reviewed reports, 1508 (55.9%) described a medication error that was associated with health IT use and 750 (49.7%) reached the patient. Improper dose errors were frequent (1214 of 1508, 80.5%) with most errors during ordering (673 of 1508, 44.6%) and reviewing medications (639 of 1508, 42.4%). Most health IT-associated medication error reports described usability issues (n = 1468 of 1508, 97.3%) including data entry, workflow support, and alerting. Data entry usability issues impacted few medication process stages, whereas workflow support and alerting impacted several stages. Conclusions Health IT usability issues are a prevalent contributing factor to medication errors, many of which reach the patient. Data entry, workflow support, and alerting should be prioritized during usability and safety optimization efforts.