Int J Med Inform - Technology-related medication errors in a tertiary hospital: a 5-year analysis of reported medication incidents.

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Resumo

RPOSE: Healthcare technology is meant to reduce medication errors. The objective of this study was to assess unintended errors related to technologies in the medication use process.METHODS: Medication incidents reported from 2006 to 2010 in a main tertiary care hospital were analysed by a pharmacist and technology-related errors were identified. Technology-related errors were further classified as socio-technical errors and device errors. This analysis was conducted using data from medication incident reports which may represent only a small proportion of medication errors that actually takes place in a hospital. Hence, interpretation of results must be tentative.RESULTS: 1538 medication incidents were reported. 17.1% of all incidents were technology-related, of which only 1.9% were device errors, whereas most were socio-technical errors (98.1%). Of these, 61.2% were linked to computerised prescription order entry, 23.2% to bar-coded patient identification labels, 7.2% to infusion pumps, 6.8% to computer-aided dispensing label generation and 1.5% to other technologies. The immediate causes for technology-related errors included, poor interface between user and computer (68.1%), improper procedures or rule violations (22.1%), poor interface between user and infusion pump (4.9%), technical defects (1.9%) and others (3.0%). In 11.4% of the technology-related incidents, the error was detected after the drug had been administered.CONCLUSIONS: A considerable proportion of all incidents were technology-related. Most errors were due to socio-technical issues. Unintended and unanticipated errors may happen when using technologies. Therefore, when using technologies, system improvement, awareness, training and monitoring are needed to minimise medication errors.

Resumo Limpo

rpose healthcar technolog meant reduc medic error object studi assess unintend error relat technolog medic use processmethod medic incid report main tertiari care hospit analys pharmacist technologyrel error identifi technologyrel error classifi sociotechn error devic error analysi conduct use data medic incid report may repres small proport medic error actual take place hospit henc interpret result must tentativeresult medic incid report incid technologyrel devic error wherea sociotechn error link computeris prescript order entri barcod patient identif label infus pump computeraid dispens label generat technolog immedi caus technologyrel error includ poor interfac user comput improp procedur rule violat poor interfac user infus pump technic defect other technologyrel incid error detect drug administeredconclus consider proport incid technologyrel error due sociotechn issu unintend unanticip error may happen use technolog therefor use technolog system improv awar train monitor need minimis medic error

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