Health Information Technology Usability Contributions to Medication Errors and Patient Safety Events
Event Type
Poster Presentation
TimeThursday, April 152:00pm - 3:00pm EDT
LocationPatient Safety Research and Initiatives
DescriptionBackground and Objective:
Health Information Technology (health IT) usability challenges are associated with increased risk of medication errors. Many health IT components support the medication cycle, including computerized provider order entry (CPOE), bar-coded medication administration (BCMA), electronic medication administration record (eMAR), Pharmacy IT, automated dispensing cabinets (ADCs), and EHR task managers. Although extensive research has been conducted on CPOE and BCMA, less is known about the usability contributions of eMAR to medication errors. Our objective was to investigate eMAR-related usability challenges that contribute to medication errors.

Methods and Analysis:
We analyzed free-text descriptions in a large sample of patient safety event reports (PSEs) related to medication health IT. Two coders first determined whether health IT contributed to each PSE. For PSEs involving a contribution from health IT, coders identified the specific health IT component that contributed to the error, usability challenge categories, and detailed usability themes. Usability categories were based on previous literature and included: Alerting, Availability of Information, Data entry, Display/Visual clutter, Interoperability, System automation and defaults, and Workflow support. Coders developed the usability themes. More than 10% of PSEs were coded to establish inter-rater reliability. Final analysis was limited to PSEs involving a contribution from eMAR.

The eMAR user interface is a significant driver of medication safety events. Detailing the specific usability challenges associated with the eMAR user interface could help to guide improvement efforts and prevent harm. Additionally, Pharmacy IT is significant upstream contributor to eMAR-associated PSEs. Dissecting the flow of information following pharmacy approval of medication may help with reducing downstream medication administration errors.