Anatomy of a failure: a sociotechnical evaluation of a laboratory physician order entry system implementation.

Linda W. Peute; Jos Aarts; Piet J M Bakker; Monique W M Jaspers

Study

Anatomy of a failure: a sociotechnical evaluation of a laboratory physician order entry system implementation.

August 26, 2009

Peute LW, Aarts J, Bakker PJM, et al. Int J Med Inform. 2010;79(4):e58-70.

View more articles from the same authors.

This qualitative study examines the factors that led to failed implementation of a computerized provider order entry system.

PubMed citation

Available at

Related Resources From the Same Author(s)

Workarounds in electronic health record systems and the revised Sociotechnical Electronic Health Record Workaround Analysis Framework: scoping review.

April 13, 2022

Implementation of computerized physician order entry in seven countries.

March 25, 2009

The impact of computerized provider order entry systems on inpatient clinical workflow: a literature review.

July 22, 2009

Evaluating the medication process in the context of CPOE use: the significance of working around the system.

May 25, 2011

Overriding of drug safety alerts in computerized physician order entry.

January 11, 2006

Clinical reasoning in the context of active decision support during medication prescribing.

April 5, 2017

Understanding handling of drug safety alerts: a simulation study.

May 5, 2010

Same system, different outcomes: comparing the transitions from two paper-based systems to the same computerized physician order entry system.

September 24, 2008

Turning off frequently overridden drug alerts: limited opportunities for doing it safely.

May 21, 2008

Time-dependent drug–drug interaction alerts in care provider order entry: software may inhibit medication error reductions.

December 2, 2009

A comparative review of patient safety initiatives for national health information technology.

February 6, 2013

Characteristics of unsafe undergraduate nursing students in clinical practice: an integrative literature review.

January 30, 2005

Ethical issues in patient safety: implications for nursing management.

June 19, 2013

How health care complexity leads to cooperation and affects the autonomy of health care professionals.

February 6, 2008

Clinicians' satisfaction with CPOE ease of use and effect on clinicians' workflow, efficiency and medication safety.

January 30, 2005

What is learning? A review of the safety literature to define learning from incidents, accidents and disasters.

February 19, 2014

Maternal mortality: near-miss events in middle-income countries, a systematic review.

November 24, 2021

A qualitative study examining the influences on situation awareness and the identification, mitigation and escalation of recognised patient risk.

January 29, 2014

Economic evaluation of interventions for prevention of hospital acquired infections: a systematic review.

January 20, 2016

The effect of implementing bar-code medication administration in an emergency department on medication administration errors and nursing satisfaction.

October 21, 2020

Surgical adverse outcomes and patients’ evaluation of quality of care: inherent risk or reduced quality of care?

December 12, 2007

Pediatric adverse event rates associated with inexperience in teaching hospitals: a multilevel analysis.

March 21, 2018

Perioperative pharmacology: a framework for perioperative medication safety.

January 19, 2011

The novice nurse and clinical decision-making: how to avoid errors.

May 11, 2011

Implementing AORN recommended practices for medication safety.

December 19, 2012

The relationship between patient safety culture and the implementation of organizational patient safety defences at emergency departments.

May 19, 2010

The effect of clinical history on accuracy of electrocardiograph interpretation among doctors working in emergency departments.

September 26, 2012

Adding automation and independent dual verification to reduce wrong blood in tube (WBIT) events.

September 28, 2022

Huddling for high reliability and situation awareness.

July 24, 2013

Use of a prospective risk analysis method to improve the safety of the cancer chemotherapy process.

November 23, 2005

Patient and visitor aggression in healthcare: a survey exploring organisational safety culture and team efficacy.

June 19, 2019

Analysis of unintended events in hospitals: inter-rater reliability of constructing causal trees and classifying root causes.

July 8, 2009

How to develop a second victim support program: a toolkit for health care organizations.

May 2, 2012

The influence that electronic prescribing has on medication errors and preventable adverse drug events: an interrupted time-series study.

December 2, 2009

January 30, 2005

Electromagnetic interference from radio frequency identification inducing potentially hazardous incidents in critical care medical equipment.

July 2, 2008

Common contributing factors of diagnostic error: a retrospective analysis of 109 serious adverse event reports from Dutch hospitals.

August 23, 2023

Kaiser Permanente's performance improvement system, part 4: creating a learning organization.

January 30, 2005

Medication dosage calculation among nursing students: does digital technology make a difference? A literature review.

September 14, 2022

Effect of a pharmacy-based centralized intravenous admixture service on the prevalence of medication errors: a before-and-after study.

August 10, 2022

Is culture associated with patient safety in the emergency department? A study of staff perspectives.

April 23, 2014

Too many, too few, or too unsafe? Impact of inappropriate prescribing on mortality, and hospitalization in a cohort ofcommunity-dwelling oldest old.

January 25, 2017

Frequency of and risk factors for medication errors by pharmacists during order verification in a tertiary care medical center.

October 7, 2015

Comparison of potential risk factors for medication errors with and without patient harm.

August 18, 2010

Is electronic health record safety a paradox?

February 23, 2022

Managing the care of patients discharged from home health: a quiet threat to patient safety?

April 4, 2007

The impact of adverse events on clinicians: what's in a name?

November 22, 2017

The Veterans Affairs root cause analysis system in action.

March 27, 2005

Disclosure of medical errors: ethical considerations for the development of a facility policy and organizational culture change.

May 11, 2005

Look-alike, sound-alike drugs review: include look-alike packaging as an additional safety check.

March 6, 2005

Does compliance to patient safety tasks improve and sustain when radiotherapy treatment processes are standardized?

December 10, 2014

Reducing treatment errors through point-of-care glucometer configuration.

October 31, 2018

Effect of automated unit dose dispensing with barcode scanning on medication administration errors: an uncontrolled before-and-after study.

December 1, 2021

Nurse–physician teamwork in the emergency department: impact on perceptions of job environment, autonomy, and control over practice.

May 8, 2013

An educational intervention to increase "speaking-up" behaviors in nurses and improve patient safety.

January 11, 2012

Comparison of methods for identifying patients at risk of medication-related harm.

July 21, 2010

Using simulation training to improve perioperative patient safety.

April 17, 2013

Just culture: it's more than policy.

August 7, 2019

Communication disparities between nursing home team members.

July 20, 2022

Clinical application of a computerized system for physician order entry with clinical decision support to prevent adverse drug events in long-term care.

January 18, 2006

Computerized physician order entry with clinical decision support in the long-term care setting: insights from the Baycrest Centre for Geriatric Care.

October 26, 2005

Defining attributes of patient safety through a concept analysis.

July 15, 2015

Personal protective equipment for preventing highly infectious diseases due to exposure to contaminated body fluids in healthcare staff.

June 3, 2020

Perception of intimidation in a perioperative setting.

January 27, 2010

Understanding patient safety and quality outcome data.

March 20, 2019

Long-term reduction in adverse drug events: an evidence-based improvement model.

July 18, 2012

Nurses' clinical reasoning: processes and practices of medication safety.

September 28, 2011

Teaching students to administer medications safely.

April 19, 2017

Sources of nurse-sensitive inpatient safety improvement.

December 21, 2022

Hospital quality-review spending and patient safety: a longitudinal analysis using instrumental variables.

July 7, 2021

Reliability of the assessment of preventable adverse drug events in daily clinical practice.

April 2, 2008

The working hours of hospital staff nurses and patient safety.

January 9, 2005

Preventable and non-preventable adverse drug events in hospitalized patients: a prospective chart review in the Netherlands.

November 9, 2011

Medication safety in a psychiatric hospital.

March 21, 2007

When the 5 rights go wrong: medication errors from the nursing perspective.

March 10, 2010

Devastatingly human: an analysis of registered nurses' medication error accounts.

June 30, 2010

Performing the wrong procedure.

September 28, 2016

Making an infusion error: the second victims of infusion therapy-related medication errors.

May 30, 2018

Exploring approaches to patient safety: the case of spinal manipulation therapy.

July 27, 2016

Hospital nurses' work environment characteristics and patient safety outcomes: a literature review.

October 12, 2016

Implementation of the Centers for Medicare & Medicaid Services' nonpayment policy for preventable hospital-acquired conditions in rural and nonrural US hospitals.

October 14, 2015

Health economic evaluation of an infection prevention and control program: are quality and patient safety programs worth the investment?

September 25, 2013

Hospital staff nurses' shift length associated with safety and quality of care.

April 17, 2013

Rapid response teams: qualitative analysis of their effectiveness.

June 19, 2013

Medication errors, routines, and differences between perioperative and non-perioperative nurses.

September 12, 2012

More than 1 million potential second victims: how many could nursing education prevent?

June 27, 2018

Post-hospital medication discrepancies at home: risk factor for 90-day return to emergency department.

June 6, 2018

Feeling unsafe in the healthcare setting: patients' perspectives.

March 8, 2017

Pediatric crisis resource management training improves emergency medicine trainees' perceived ability to manage emergencies and ability to identify teamwork errors.

January 28, 2015

Affective influences on clinical reasoning and diagnosis: insights from social psychology and new research opportunities.

October 19, 2022

Patient safety when receiving telephone advice in primary care - a Swedish qualitative interview study.

February 23, 2022

Using medical malpractice closed claims data to reduce surgical risk and improve patient safety.

April 25, 2007

Effects of nurse staffing and nurse education on patient deaths in hospitals with different nurse work environments.

January 25, 2012

Creating an improvement culture for enhanced patient safety: service improvement learning in pre-registration education.

November 3, 2010

Losing the moment: understanding interruptions to nurses' work.

May 19, 2010

Safety issues related to the electronic medical record (EMR): synthesis of the literature from the last decade, 2000–2009.

March 9, 2011

Using simulation to improve first-year pharmacy students' ability to identify medication errors involving the top 100 prescription medications.

August 24, 2016

Reason's accident causation model: application to adverse events in acute care.

February 13, 2013

Factors associated with post-intensive care unit adverse events: a clinical validation study.

October 29, 2014

Journal Article

Study

Pilot implementation of a health equity checklist to improve the identification of equity-related adverse events.

March 29, 2023

Related Resources

Analysis of the nature and contributory factors of medication safety incidents following hospital discharge using National Reporting and Learning System (NRLS) data from England and Wales: a multi-method study.

June 7, 2023

Patient Safety Innovations

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

May 31, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

Interview

In Conversation with... Susan McGrath, PhD and George Blike, MD about Surveillance Monitoring

April 26, 2023

Perspective

Surveillance Monitoring to Improve Patient Safety in Acute Hospital Care Units

April 26, 2023

Perspectives on Safety

Annual Perspective

Technology as a Tool for Improving Patient Safety

March 29, 2023

Safety risks and workflow implications associated with nursing-related free-text communication orders.

March 15, 2023

Discontinuation of outpatient medications: implications for electronic messaging to pharmacies using CancelRx.

December 7, 2022

Free-text computerized provider order entry orders used as workaround for communicating medication information.

August 31, 2022

Assessment of health information technology-related outpatient diagnostic delays in the US Veterans Affairs health care system: a qualitative study of aggregated root cause analysis data.

July 22, 2020

Automation of the I-PASS tool to improve transitions of care.

October 23, 2019

Overview of the Environmental Scan of Primary Care-Based Effort To Reduce Readmissions.

March 27, 2019

Improving communication with primary care physicians at the time of hospital discharge.

February 8, 2017

Pharmacist–physician communications in a highly computerised hospital: sign-off and action of electronic review messages.

August 24, 2016

Incorporating indications into medication ordering—time to enter the age of reason.

August 10, 2016

WebM&M Cases

Hyperglycemia and Switching to Subcutaneous Insulin

December 1, 2015

Interview

In Conversation With… Vineet Arora, MD, MAPP

September 1, 2015

Health information exchange in emergency medicine.

August 19, 2015

High incidence of medication documentation errors in a Swiss university hospital due to the handwritten prescription process.

November 2, 2011

Why patient summaries in electronic health records do not provide the cognitive support necessary for nurses' handoffs on medical and surgical units: insights from interviews and observations.

October 19, 2011

Prevalence of medication administration errors in two medical units with automated prescription and dispensing.

September 28, 2011

Physician reporting of clinically significant events through a computerized patient sign-out system.

September 14, 2011

Developing a programme for medication reconciliation at the time of admission into hospital.

September 7, 2011

Increasing adoption of computerized provider order entry, and persistent regional disparities, in US emergency departments.

August 31, 2011

Does the implementation of an electronic prescribing system create unintended medication errors? A study of the sociotechnical context through the analysis of reported medication incidents.

July 27, 2011

National study on the frequency, types, causes, and consequences of voluntarily reported emergency department medication errors.

June 29, 2011

Can an electronic prescribing system detect doctors who are more likely to make a serious prescribing error?

June 8, 2011

Evaluating the medication process in the context of CPOE use: the significance of working around the system.

May 25, 2011

Does user-centred design affect the efficiency, usability and safety of CPOE order sets?

May 4, 2011

See More About The Topic

General Hospitals

Health Care Executives and Administrators

Information Professionals

Discontinuities, Gaps, and Hand-Off Problems

Communication between Providers

Anatomy of a failure: a sociotechnical evaluation of a laboratory physician order entry system implementation.

Pilot implementation of a health equity checklist to improve the identification of equity-related adverse events.

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Anatomy of a failure: a sociotechnical evaluation of a laboratory physician order entry system implementation.

Pilot implementation of a health equity checklist to improve the identification of equity-related adverse events.

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site