Medication safety incidents in paediatric oncology after electronic medication management system implementation

Abstract

Objective To explore medication safety issues related to use of an electronic medication management system (EMM) in paediatric oncology practice, through the analysis of patient safety incident reports. Methods We analysed 827 voluntarily reported incidents relating to oncology patients that occurred over an 18‐month period immediately following implementation of an EMM in a paediatric hospital in Australia. We identified medication‐related and EMM‐related incidents and carried out a content analysis to identify patterns. Results We found ~79% (n = 651) of incidents were medication‐related and, of these, ~45% (n = 294) were EMM‐related. Medication‐related incidents included issues with: prescribing; dispensing; administration; patient transfers; missing chemotherapy protocols and information on current stage of patient treatment; coordination of chemotherapy administration; handling or storing medications; children or families handling medications. EMM‐related incidents were classified into four groups: technical issues, issues with the user experience, unanticipated problems in EMM workflow, and missing safety features. Conclusions Incidents reflected difficulties with managing therapies rich in interdependencies. EMM, and especially its ‘automaticity’, contributed to these incidents. As EMM impacts on safety in such high‐risk settings, it is essential that users are aware of and attend to EMM automatic behaviours and are equipped to troubleshoot them.

Usability evaluation of an integrated electronic medication management system implemented in an Oncology setting using the Unified Theory of the Acceptance and Use of Technology.

“…The interrelated nature of facilitating condition and its downstream impact on user groups demonstrated this. A lack of understanding of system functionality often results in independent troubleshooting by users, skipping steps or entering information in the EMMS differently to overcome system barriers [2]. By doctors not initially appreciating the source of the problem when prescribing, in a strongly multidisciplinary unit, it had downstream consequences for other user's (pharmacists and nurses) work ow.…”

“…However, we also identi ed oncology speci c issues related to protocol-mandated care. A major limitation in exibility was found when doctors attempted to order outside the order sets [2] and when adjusting doses or frequencies. The perception of the system was that it lacked the exibility required in the oncology setting, which was paradoxically often a symptom of systems attempting to improve safety [29].…”

“…However, no study has applied the UTAUT framework to explore usability in the Oncology EMMS setting. Furthermore, previous studies exploring Oncology EMMS have predominately focused on usability from a single user perspective in isolation, such as prescribers [17], EMMS providers [18], user requirements before implementation [19] or its impact on medication safety [2,20].…”

A Qualitative Evaluation of the Usability of a Hospital-Wide Electronic Medication Management System in the Oncology setting using the Unified Theory and Use of Technology Framework

“…The interrelated nature of facilitating condition and its downstream impact on user groups demonstrated this. Lack of understanding of system functionality often results in independent troubleshooting by users, skipping steps or entering information in the EMMS differently to overcome system barriers [22]. By doctors not initially appreciating the source of the problem when prescribing, in a strongly multidisciplinary unit, it had downstream consequences for other user's (pharmacists and nurses) work ow.…”

“…However, we also identi ed oncology speci c issues related to protocol-mandated care. A major limitation in exibility was found when doctors attempted to order outside the order sets [22], when adjusting doses or frequencies. The perception of the system was that it lacked the exibility required in the oncology setting, which was paradoxically often a symptom of systems attempting to improve safety [11].Like previous studies [17], automaticity contributed to a negative user experience to a degree [22], as users (doctors and pharmacists) felt reduced e cacy was being facilitated by a greater number of mouse clicks [32] and effort were required to prescribe or review medications outside of standardised order sets.…”