Appendix A: Summary of the 21 studies investigating HIT incidents Authors Study Source/ Country Settings HIT types N Harm, % Case study/ incident Summary of findings (year) period case study (death, analyses methods (mths) n) R: reporting format HIT: problem categories C: consequences Horsky et al. case study USA inpatient CPOE 1 1 - semi-structured An elderly patient suffering from (2005) (13) interviews with involved hypokalemia or low potassium (serum clinicians potassium was 3.1 mEq/L; creatinine, 1.7) - computer log analysis became severely hyperkalemic (serum - usability inspection of potassium level, 7.8 mEq/L). Wrong, CPOE interface incomplete and missing information in the - quality assurance reports hospital order entry system resulted in the - case & review notes by patient receiving multiple doses of Significant Events potassium. In total, 316 mEq potassium Committee chloride (KCl) was administered over 42 hours. Technical problems related to software functionality such as suboptimal screen display and lack of automated checking function. Human factors issues were linked with inadequate training and poor familiarity with the system. Landman et al. case study USA inpatient ED- Image N/A computer log analysis An update to Microsoft Internet Explorer (2013) (14) viewer severed the link between the ED tracking board and web-based image viewer. The loss of this link resulted in decreased image viewer access rates for ED patients during the 10 days of the incident (2.8 views/study) compared with image review rates for a similar 10-day period preceding this event (3.8 views/study, p<0.001).
Appendix A: Summary of the 21 studies investigating HIT incidents Authors (year) Study period (mths) Source/ case study Country Settings HIT types N Harm, % (death, n) Case study/ incident analyses methods R: reporting format HIT: problem categories C: consequences Summary of findings Horsky et al. (2005) (13) case study USA inpatient CPOE 1 1 - semi-structured interviews with involved clinicians - computer log analysis - usability inspection of CPOE interface - quality assurance reports - case & review notes by Significant Events Committee An elderly patient suffering from hypokalemia or low potassium (serum potassium was 3.1 mEq/L; creatinine, 1.7) became severely hyperkalemic (serum potassium level, 7.8 mEq/L). Wrong, incomplete and missing information in the hospital order entry system resulted in the patient receiving multiple doses of potassium. In total, 316 mEq potassium chloride (KCl) was administered over 42 hours. Technical problems related to software functionality such as suboptimal screen display and lack of automated checking function. Human factors issues were linked with inadequate training and poor familiarity with the system. Landman et al. (2013) (14) case study USA inpatient ED- Image viewer N/A computer log analysis An update to Microsoft Internet Explorer severed the link between the ED tracking board and web-based image viewer. The loss of this link resulted in decreased image viewer access rates for ED patients during the 10 days of the incident (2.8 views/study) compared with image review rates for a similar 10-day period preceding this event (3.8 views/study, p<0.001).