Stakeholder perspectives of system-related errors: Types, contributing factors, and consequences

Area of Science:

• Health Informatics
• Patient Safety
• Human Factors Engineering

Background:

• Electronic medication management systems (EMMS) offer benefits but also introduce novel safety risks.
• Qualitative research on system-related errors stemming from EMMS use is limited.
• Understanding stakeholder perceptions is crucial for addressing these emergent risks.

Purpose of the Study:

• To explore stakeholders' in-depth perceptions and experiences of system-related errors associated with EMMS.
• To identify contributing factors and consequences of these errors.
• To inform strategies for enhancing patient safety in digital health environments.

Main Methods:

• Semi-structured interviews were conducted with EMMS users and support staff in a Sydney local health district.
• A general inductive approach was used for iterative analysis.
• Data were mapped to Reason's accident causation model, categorizing errors, latent conditions, and consequences.

Main Results:

• Omission errors (e.g., failure to check duplicate orders) were frequently reported unsafe acts, alongside commission errors and workarounds.
• Poor EMMS design, user overreliance, and organizational factors (e.g., system downtime) were identified as key contributors.
• Consequences included medication errors, system impacts, and adverse effects on healthcare workers.

Conclusions:

• EMMS design is a significant factor in system-related errors, but user and organizational factors are equally important.
• Minimizing system-related errors requires a multi-faceted strategy addressing both the EMMS and its implementation context.
• A holistic approach is essential for improving safety in electronic medication management.