Unintended prescribing errors?
Post date: May 24, 2011 2:52:15 PM
A pre-publication paper by Redwood et al (2011) is available from BMC Medical Informatics and Decision Making Journal. The title is "Does the implementation of an electronic prescribing system create unintended medication errors? A study of the sociotechnical context through the analysis of reported medication incidents".
I've added the e-iatrogenesis errors they uncovered. These include the usual suspects:
User interface including pick list error or free-text input error
Distraction caused by alerts
Prescribing roles restrictions results in no treatment or unauthorized treatment
Two of the errors I haven't seen before. Apparently a user must be logged on to the system to "sign" that the medication has been given but a user can administer the medication without signing on.
Log-in/log-off status for "signing"
Treatment duplication attributed to "signing" versus "administering"
These "signing" errors require further attention. One of hospitals I've been studying has an old system (no GUI) so the authorization is just a passcode on the medication line. There isn't logging on/off. It is more like a digital paper chart where the nurse initials when administered. Something to consider.