McDonald et al. case study USA inpatient CPOE 1 - - medical case history Computerised bar-coding patient (2006) (15) - root-cause analyses identification system was associated with a - interviews with involved near miss. Human factor issues involved patients and clinicians rule violation and integration with workflow such as missing verbal confirmation of patient identification and entering wrong information into a system. Castro et al. Sentinel USA inpatient, EHR, CPOE, 120 125^ R: voluntary reports + RCA 120 HIT-related sentinel events from 3,375 (2016) (23) 2013 events to eMAR, PIS, (66) findings reported affecting 125 patients. (42) The Joint CDS, Commission imaging, HIT: 4 schemas Contributing factors were most frequently -AHRQ Common Formats associated with the human-computer peripheral device, -AHRQ Hazard Manager interface, workflow and communication, billing, ontology and clinical content–related issues. - Magrabi et al. classification AutoDisp, LIS - Sittig and Singh’s The three most frequently identified event types were (1) medication errors, (2) sociotechnical model wrong-site surgery (including the wrong C: 15 categories of sentinel side, wrong procedure, and wrong patient), events and (3) delays in treatment. Cheung et al. Dutch The inpatient, CPOE, EHR, 668 58% (2) R: CMR database Half of the incidents were associated with (2013) (31) central outpatient AutoDisp, use error related wrong entry to the system. (12) medication pharmacy PIS, HIT: Technical problems related to poor design incidents Infusion - Magrabi et al. classification of screens were associated with the most - phases of medication registration pump, incidents in community pharmacies for (CMR) eMAR process choosing the wrong medicine.
McDonald et al. (2006) (15) case study USA inpatient CPOE 1 - - medical case history - root-cause analyses - interviews with involved patients and clinicians Computerised bar-coding patient identification system was associated with a near miss. Human factor issues involved rule violation and integration with workflow such as missing verbal confirmation of patient identification and entering wrong information into a system. Castro et al. (2016) (23) (42) Sentinel events to The Joint Commission USA inpatient, EHR, CPOE, eMAR, PIS, CDS, imaging, peripheral device, billing, AutoDisp, LIS 120 125^ (66) R: voluntary reports + RCA findings HIT: 4 schemas -AHRQ Common Formats -AHRQ Hazard Manager ontology - Magrabi et al. classification - Sittig and Singh’s sociotechnical model C: 15 categories of sentinel events 120 HIT-related sentinel events from 3,375 reported affecting 125 patients. Contributing factors were most frequently associated with the human-computer interface, workflow and communication, and clinical content–related issues. The three most frequently identified event types were (1) medication errors, (2) wrong-site surgery (including the wrong side, wrong procedure, and wrong patient), and (3) delays in treatment. Cheung et al. (2013) (31) (12) Dutch central medication incidents registration (CMR) The inpatient, outpatient pharmacy CPOE, EHR, AutoDisp, PIS, Infusion pump, eMAR 668 58% (2) R: CMR database HIT: - Magrabi et al. classification - phases of medication process Half of the incidents were associated with use error related wrong entry to the system. Technical problems related to poor design of screens were associated with the most incidents in community pharmacies for choosing the wrong medicine. 2013