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Systems failure in hospitals--using Reason's model to predict problems in a prescribing information system
1Department of Information Systems, University of Melbourne, Victoria 3010, Australia. reeval@staff.dis.unimelb.edu.au
Journal of Medical Systems
|April 21, 2005
Summary
Medication prescribing errors in hospitals are costly. Poor information systems contribute to these errors, particularly when information is unavailable or inaccessible, highlighting a need for improved hospital information systems.
Area of Science:
- Health Informatics
- Medical Error Analysis
- Public Health Systems
Background:
- Medication prescribing errors impose significant financial burdens on hospitals and patients within public health systems.
- Addressing the root causes of these errors is crucial for improving patient safety and healthcare efficiency.
Purpose of the Study:
- To investigate the role of poor information systems as a contributing factor to medication prescribing errors.
- To measure the extent of the link between information delivery failures and prescribing errors.
Main Methods:
- Qualitative research conducted through interviews and a survey instrument within an HIV ward of a large public hospital.
- Application of Reason's model for predicting systems error to analyze information systems failures in the prescribing process.
Main Results:
- A significant number of prescribing errors were found to be associated with unavailable or inaccessible health information.
- The study quantifies, for the first time, the link between information delivery problems and prescribing errors.
Conclusions:
- Failures in hospital information systems, particularly information unavailability and inaccessibility, are directly linked to medication prescribing errors.
- Implementing more effective information systems is essential to mitigate risks and reduce losses for all stakeholders in the healthcare system.