Process Approach for Managing Health Information System-Induced Medication Errors.

Area of Science:

• Healthcare Informatics
• Patient Safety
• Clinical Workflow Analysis

Background:

• Medication errors stemming from health information systems (HIS) and clinical workflows compromise patient care quality.
• Understanding the factors contributing to HIS-induced errors is crucial for improving healthcare delivery.

Purpose of the Study:

• To evaluate the medication process's error risk, control, and impact within a Japanese secondary care teaching hospital.
• To analyze latent and active factors contributing to HIS-induced medication errors using a process perspective.

Main Methods:

• A case study was conducted in a 1000-bed Japanese secondary care teaching hospital.
• Data collection involved observation, interviews, and document analysis.
• The Human, Organisation, Process, and Technology-fit framework was adopted for analysis.

Main Results:

• Process factors influencing medication error risk include system design (templates, calendars, intuitive interfaces), barcode checks, ease of use, and alerts.
• Organizational factors such as policy, systematic task organization, and a strong safety culture significantly impact error management.
• Effective approaches to managing medication errors are vital for error reduction and optimizing clinical workflows.

Conclusions:

• The study highlights key process and organizational factors contributing to medication errors within HIS.
• The Human, Organisation, Process, and Technology-fit framework provides valuable insights for evaluating and mitigating HIS-induced errors.
• Findings underscore the importance of system design, usability, and safety culture in enhancing medication safety and patient care quality.