TY - JOUR
T1 - Risk factors associated with medication ordering errors
AU - Abraham, Joanna
AU - Galanter, William L.
AU - Touchette, Daniel
AU - Xia, Yinglin
AU - Holzer, Katherine J.
AU - Leung, Vania
AU - Kannampallil, Thomas
N1 - Publisher Copyright:
© 2020 The Author(s).
PY - 2021/1/1
Y1 - 2021/1/1
N2 - Objective: We utilized a computerized order entry system-integrated function referred to as "void"to identify erroneous orders (ie, a "void"order). Using voided orders, we aimed to (1) identify the nature and characteristics of medication ordering errors, (2) investigate the risk factors associated with medication ordering errors, and (3) explore potential strategies to mitigate these risk factors. Materials and Methods: We collected data on voided orders using clinician interviews and surveys within 24 hours of the voided order and using chart reviews. Interviews were informed by the human factors-based SEIPS (Systems Engineering Initiative for Patient Safety) model to characterize the work systems-based risk factors contributing to ordering errors; chart reviews were used to establish whether a voided order was a true medication ordering error and ascertain its impact on patient safety. Results: During the 16-month study period (August 25, 2017, to December 31, 2018), 1074 medication orders were voided; 842 voided orders were true medication errors (positive predictive value = 78.3 ± 1.2%). A total of 22% (n = 190) of the medication ordering errors reached the patient, with at least a single administration, without causing patient harm. Interviews were conducted on 355 voided orders (33% response). Errors were not uniquely associated with a single risk factor, but the causal contributors of medication ordering errors were multifactorial, arising from a combination of technological-, cognitive-, environmental-, social-, and organizational-level factors. Conclusions: The void function offers a practical, standardized method to create a rich database of medication ordering errors. We highlight implications for utilizing the void function for future research, practice and learning opportunities.
AB - Objective: We utilized a computerized order entry system-integrated function referred to as "void"to identify erroneous orders (ie, a "void"order). Using voided orders, we aimed to (1) identify the nature and characteristics of medication ordering errors, (2) investigate the risk factors associated with medication ordering errors, and (3) explore potential strategies to mitigate these risk factors. Materials and Methods: We collected data on voided orders using clinician interviews and surveys within 24 hours of the voided order and using chart reviews. Interviews were informed by the human factors-based SEIPS (Systems Engineering Initiative for Patient Safety) model to characterize the work systems-based risk factors contributing to ordering errors; chart reviews were used to establish whether a voided order was a true medication ordering error and ascertain its impact on patient safety. Results: During the 16-month study period (August 25, 2017, to December 31, 2018), 1074 medication orders were voided; 842 voided orders were true medication errors (positive predictive value = 78.3 ± 1.2%). A total of 22% (n = 190) of the medication ordering errors reached the patient, with at least a single administration, without causing patient harm. Interviews were conducted on 355 voided orders (33% response). Errors were not uniquely associated with a single risk factor, but the causal contributors of medication ordering errors were multifactorial, arising from a combination of technological-, cognitive-, environmental-, social-, and organizational-level factors. Conclusions: The void function offers a practical, standardized method to create a rich database of medication ordering errors. We highlight implications for utilizing the void function for future research, practice and learning opportunities.
KW - CPOE
KW - SEIPS
KW - human factors
KW - medication ordering errors
KW - medication voiding
UR - http://www.scopus.com/inward/record.url?scp=85100125362&partnerID=8YFLogxK
U2 - 10.1093/jamia/ocaa264
DO - 10.1093/jamia/ocaa264
M3 - Article
C2 - 33221852
AN - SCOPUS:85100125362
SN - 1067-5027
VL - 28
SP - 86
EP - 94
JO - Journal of the American Medical Informatics Association
JF - Journal of the American Medical Informatics Association
IS - 1
ER -