Related Experiment Video
Updated: May 18, 2026
Improving IV Insulin Administration in a Community Hospital
Published on: June 11, 2012
Reported medication errors after introducing an electronic medication management system
1Epworth Deakin Centre for Clinical Nursing Research, Richmond, Vic, Australia. bernice.redley@deakin.edu.au
Aims And Objectives:
To explore the effects of introducing an electronic medication management system on reported medication errors.
Background:
Computerised medication management systems have been found to improve medication safety; however, introducing medication management system into healthcare environments can create unanticipated or new problems and opportunities for medication error.
Design:
Descriptive analysis of medication error reports.
Methods:
This was a retrospective analysis of 359 incident reports drawn from the period of 1 May 2005-30 April 2006 across two hospital sites of a single not-for-profit private health service located in metropolitan Melbourne. Site A used a conventional pen and paper system for medication management, and Site B had introduced a computerised medication management system.
Results:
Most medication errors occurred at the nurse administration (71·5%) and prescribing (16·4%) stages of delivery. The most common medication error type reported at Site A was omission (33%), and at Site B was wrong documentation (24·2%). A higher proportion of errors at the prescribing phase, and less nurse administration errors, were detected at Site B where the medication management system was in use. The incidence of other, less frequent errors was similar across the two hospital sites.
Conclusions:
This examination of medication error reports suggests there are differences in the types of medication errors that are reported in association with the introduction of electronic medication management system compared to pen and paper system systems. The findings provide a new insight into the effects of introducing an electronic medication management system on the types of medication errors reported.
Relevance To Clinical Practice:
The findings provide a new insight into the types of medication errors that are reported during implementation of an electronic medication management system. Extra support for physicians prescribing practices should be considered.
Insights
Introducing electronic medication management systems shifted reported errors from omissions to documentation issues. The study highlights changes in medication error types post-implementation, suggesting a need for enhanced physician support.
Area of Science:
- Health Informatics
- Patient Safety
- Clinical Pharmacy
Background:
- Computerized medication management systems (CMMS) are recognized for enhancing medication safety.
- However, CMMS implementation can introduce novel challenges and opportunities for medication errors within healthcare settings.
Purpose of the Study:
- To investigate the impact of implementing an electronic medication management system (eMMS) on the nature of reported medication errors.
- To compare medication error profiles between a site using a traditional pen-and-paper system and a site utilizing an eMMS.
Main Methods:
- A retrospective analysis of 359 incident reports from two hospital sites over a 12-month period.
- Site A employed a conventional pen-and-paper medication management system.
- Site B utilized a newly introduced computerized medication management system.
Main Results:
- The majority of medication errors occurred during nurse administration (71.5%) and prescribing (16.4%).
- Site A (pen-and-paper) reported omission errors most frequently (33%), while Site B (eMMS) reported wrong documentation errors most frequently (24.2%).
- Site B demonstrated a higher proportion of prescribing errors and fewer nurse administration errors compared to Site A.
Conclusions:
- The introduction of an eMMS alters the types of medication errors reported, shifting the pattern from traditional issues like omissions.
- Findings offer valuable insights into the evolving landscape of medication errors during eMMS implementation.
- Clinical practice should consider targeted support for physician prescribing within eMMS environments.
Related Concept Videos
01:25Errors occurring during blood pressure monitoring
Several factors...
01:18Guidelines and Strategies for Safe Computer Charting
Maintain Confidentiality and Security:
01:26Pharmaceutical Poisoning: Potential Scenarios
01:30Methods of Documentation VII: EMR
01:15Systematic Error: Methodological and Sampling Errors
Sampling errors originate from improper sampling methods or the wrong sample population. These errors can be minimized by refining the sampling strategy. Defective instruments or faulty calibrations are the sources of instrumental...
01:10Documentation of Nursing Diagnosis
In some settings, data-driven computerized decision support systems are in place, allowing for more accurate nursing diagnoses. The database within one of these systems includes diagnostic labels defining characteristics, activities, and indicators for nursing. A nurse enters assessment...