Electronic Medication Management Systems for Improving Safe Use of Medications
the underlying organizational processes (e.g., hospital or clinic) and underlying workflows can lead to the potential for new types of errors occurring.7
For example, particular user interface
features and issues (such as unclear navigational paths, obscured patient data on computer screens, and inappropriate medication dosage defaults in menus) have been shown to be statistically related to medication errors.10
These types of errors, which are inadvertently
caused through the use of information systems, have been termed by Borycki and colleagues as ‘technology-induced errors.’7,10
Other
researchers such as Koppel have also described a number of ‘workarounds,’ which include a variety of practices (many of which are themselves unsafe or error prone) of health professionals to work around the limitations and problems that may be encountered when using healthcare IT.11
Some researchers have even documented phenomena such as ‘alert fatigue’ (where computer-generated alerts may be perceived as being triggered too frequently by health professionals and consequently ‘turned off’).12
What Can be Done to Maximize Benefits? Many of the issues, barriers, and problems surrounding effective implementation of healthcare IT are common across national boundaries and even across specific systems. At a general level, to address these issues, a broadly based perspective is needed, involving consideration of the degree of fit between a new healthcare IT system and the organization which has purchased it and into which it is to be deployed. It is agued that, the greater the fit between a particular system and the organization in which it is to be deployed, the more likely the safety benefits of healthcare IT are to be realized (while the inadvertent negative consequences will be lessened). Furthermore, there is a growing body of evidence that this relationship holds regardless of whether a system is developed in-house (as is the case of many of the systems that provided evidence of benefits) or whether it is a commercially available system purchased by a healthcare organization (as is more likely the case).7
In order to
understand and characterize system–organization fit, work emerging from the areas of human factors, cognitive science, and socio-technical design in healthcare is extremely relevant. Furthermore, there are a number of areas where progress is being made in improving the chances for success of implementing healthcare IT, and in particular medication administration systems.
Need for Improved Healthcare System Design The introduction of new healthcare IT systems has been associated with issues and problems that have their origin in the design and implementation of these systems.13
Issues related to lack of
user/organizational acceptance and problems encountered by users of many specific health information systems have been reported in the literature and, as a consequence, an entire body of literature has appeared discussing barriers to IT system adoption. Many of these problems are related to socio-technical issues, including organizational difficulties in implementing systems.14,15
In addition, the
actual design processes involved in the creation of new healthcare IT systems have come under more recent scrutiny, with calls for application, consideration, and adaptation of methods that have been
iHEALTH CONNECTIONS
Furthermore, researchers have found that certain features of user interfaces may be associated with prescribing errors if poorly designed and implemented.8,9
used in other industries where there is considerable potential for risk of project failure, as well as risk for potential harm to humans (e.g., as in the aviation industry).16
While some argue that safety standards for
the development of healthcare information systems have lagged behind other industries, there have been recent attempts to encourage or require the use of more rigorous processes and safer methods, as will be discussed.17
Human Factors Analysis
One of the most critical areas for improving system effectiveness and safety to maximize benefits is at the interface between system and user, i.e., at the level of human–computer interaction. Considered broadly, the field of human–computer interaction deals with improving the usability of systems for individual users and facilitating the effective application of IT in group and organizational settings.18
A wide range of
methods have now appeared in healthcare that provide scientific guidance for designing, testing, implementing, and selecting systems. Among these methods, usability testing and more recent application of clinical simulations have proven to be beneficial in the analysis of commercial CPOE products as well as in the design and implementation of these systems.19,20
Furthermore, work in locating
where technology-induced errors arise from has clearly shown that consideration must be given to the end-user interaction and to what the effects of decisions made throughout the system development life cycle have on end-user acceptance. Taking this further, organizational decisions and policy regulations are likely to have a large impact (although often indirectly) on whether a system deployed within an organization will function as expected and will match organizational needs and safety standards.
Improving System Testing Prior to Deployment Recent work in attempting to maximize the benefits of medication administration systems has involved work in the area of extending testing of systems prior to their deployment.21
It has been argued that
conventional testing of systems applied in healthcare may not be sufficient to ensure maximal benefits and safety within complex healthcare contexts. Along these lines, Kushniruk and colleagues have examined what they term as ‘computer-centric’ testing methods (which focus on correctness of information systems often in isolation of application in complex healthcare settings) and ‘user-centric’ methods (which have a strong focus on user testing and usability).16
It is argued
that, prior to release of systems in settings such as hospitals, electronic medication management systems should undergo a full range of testing methods that include both computer-centric methods (which is the norm) and user-centric methods, such as testing systems under a wide array of complex real-world conditions (which unfortunately is not the norm). At a practical level, those responsible for the safety of systems in their organizations should become cognizant of the range of methods that need to be deployed to both assess systems for fit within the organization and provide practical feedback for their modification and customization to local work practices.16
System Procurement Practices
Perhaps one of the most powerful ways in which healthcare organizations can work to improve system–organization fit is in improving the selection of systems for implementation. Along these
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