Understanding Health Information Technology Induced Medication Safety Events by Two Conceptual FrameworksFunding This project is supported by the Agency for Healthcare Research and Quality (grant number R01HS022895) and the UTHealth Innovation for Cancer Prevention Research Training Program Postdoctoral Fellowship (Cancer Prevention and Research Institute of Texas; grant #RP160015). The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality.
21 September 2018
07 January 2019
06 March 2019 (online)
Background While health information technology (health IT) is able to prevent medication errors in many ways, it may also potentially introduce new paths to errors. To understand the impact of health IT induced medication errors, this study aims to conduct a retrospective analysis of medication safety reports.
Methods From the U.S. Food and Drug Administration (FDA) Manufacturer and User Facility Device Experience database, we identified reports in which health IT is a contributing factor to medication errors. We applied two conceptual frameworks, Sittig and Singh's sociotechnical model and Coiera's information value chain, to examine the identified reports.
Results We identified 152 unique reports on health IT induced medication errors as the final report set for review. The majority (65.13%) of the reports involved multiple contributing factors according to the sociotechnical model. Three dimensions, that is, clinical content, human–computer interface, and people, were involved in more reports than the others. The transition of the effects of health IT on medication practice was summarized using information value chain. Health IT related contributing factors may lead to receiving wrong information, missing information, receiving partial information and delayed information, and receiving wrong information and missing information tend to cause the commission errors in decision-making.
Conclusion The two frameworks provide an opportunity to understand a comprehensive context of safety event and the impact of health IT induced errors on medication safety. The sociotechnical model helps identify the aspects causing medication safety issues. The information value chain helps uncover the effect of the health IT induced medication errors on health care process and patient outcomes.
Protection of Human and Animal Subjects
No human/animal subjects were involved in the project.
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