Unintended consequences of pharmacy information systems: A case study

Area of Science:

• Health Informatics
• Patient Safety
• Socio-technical Systems Analysis

Background:

• Pharmacy information systems (PhIS) can inadvertently introduce medication errors.
• Pharmacists' workload and comprehension of information quality maintenance impact error detection.
• Unintended consequences of PhIS pose risks to patient safety.

Purpose of the Study:

• Identify factors influencing unintended consequences of PhIS.
• Analyze the effect of these factors on information quality.
• Determine risks to patient safety associated with PhIS.

Main Methods:

• Qualitative, explanatory case study of PhIS in ambulatory pharmacies.
• Data collection via observations, interviews, and document analysis.
• Application of socio-technical interactive analysis (ISTA) and human-organization-process-technology-fit (HOPT-fit) frameworks.

Main Results:

• Identified 28 unintended consequences of PhIS.
• Key factors include system rigidity, complexity, unclear knowledge, hybrid documentation, workflow issues, and time pressure leading to cognitive overload.
• Mitigation strategies involve human factor principles, data quality improvement, training, master data management, and standardizing workarounds.

Conclusions:

• PhIS can threaten information quality due to poor design, lack of coordination, and user misunderstanding.
• Safe system design and user awareness are crucial for maintaining PhIS information quality and ensuring patient safety.
• The proposed evaluation approach aids in identifying complex socio-technical interactions and mitigation strategies.