Lichtner, V;
Baysari, M;
Gates, P;
Dalla-Pozza, L;
Westbrook, JI;
(2019)
Medication safety incidents in paediatric oncology after electronic medication management system implementation.
European Journal of Cancer Care
, 28
(6)
, Article e13152. 10.1111/ecc.13152.
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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.
| Type: | Article |
|---|---|
| Title: | Medication safety incidents in paediatric oncology after electronic medication management system implementation |
| Open access status: | An open access version is available from UCL Discovery |
| DOI: | 10.1111/ecc.13152 |
| Publisher version: | https://doi.org/10.1111/ecc.13152 |
| Language: | English |
| Additional information: | Copyright © 2019 The Authors. European Journal of Cancer Care published by John Wiley & Sons Ltd. This is an open access article under the terms of the Creative Commons Attribution‐NonCommercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes. / This study received funding from the European Union’s Horizon 2020 research and innovation programme under the Marie-Skłodowska Curie Grant Agreement number 740131. This paper reflects only the author(s)' view. The European Commission and its Research Executive Agency are not responsible for any use that may be made of the information it contains. |
| Keywords: | Paediatrics; Medication Errors; Computerized Provider Order Entry System; Patient Safety; Hospital Oncology Services; Evaluation Research |
| UCL classification: | UCL UCL > Provost and Vice Provost Offices > School of Life and Medical Sciences UCL > Provost and Vice Provost Offices > School of Life and Medical Sciences > Faculty of Life Sciences UCL > Provost and Vice Provost Offices > School of Life and Medical Sciences > Faculty of Life Sciences > UCL School of Pharmacy UCL > Provost and Vice Provost Offices > School of Life and Medical Sciences > Faculty of Life Sciences > UCL School of Pharmacy > Practice and Policy |
| URI: | https://discovery.ucl.ac.uk/id/eprint/10081795 |
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