Identifying Health Information Technology Usability Issues Contributing to Medication Errors Across Medication...

Area of Science:

• Health Informatics
• Patient Safety
• Medication Management

Background:

• Health information technology (health IT) systems are crucial for medication ordering, reviewing, and administration.
• Understanding medication errors linked to health IT is vital for improving patient safety.

Purpose of the Study:

• To identify medication errors associated with health IT use.
• To determine if these errors reached patients.
• To pinpoint the medication process stage and specific usability issues contributing to these errors.

Main Methods:

• Analysis of patient safety event reports from over 595 healthcare facilities (January 2013 - September 2018).
• Computational identification of reports related to computerized provider order entry, electronic medication administration records, and barcode medication administration.
• Manual review of 2700 reports to categorize errors, process stages, and usability issues.

Main Results:

• Over 55% of reviewed reports (1508) detailed health IT-associated medication errors, with nearly 50% reaching patients.
• Improper dose errors were most common (80.5%), occurring primarily during medication ordering and reviewing.
• Usability issues, particularly data entry, workflow support, and alerting, were reported in 97.3% of errors.

Conclusions:

• Health IT usability issues are a significant factor in medication errors, many of which impact patients.
• Improving data entry, workflow support, and alerting functionalities in health IT systems is essential for safety optimization.