EHR-related medication errors in two ICUs.

Pascale Carayon; Shimeng Du; Roger L. Brown; Randi Cartmill; Mark Johnson; Tosha B. Wetterneck

Study

EHR-related medication errors in two ICUs.

February 8, 2017

Carayon P, Du S, Brown RL, et al. J Healthc Risk Manag. 2017;36(3):6-15.

View more articles from the same authors.

Despite the demonstrated success of technology in reducing medication errors, preventable adverse drug events remain a significant source of harm to patients. Researchers analyzed data on medication safety events in 2 ICUs at a medical center and found 1622 preventable adverse drug events among 624 patients. About one third of these events were related to electronic health record use, including duplicate orders.

PubMed citation

Available at

Related Resources From the Same Author(s)

Changes in end-user satisfaction with computerized provider order entry over time among nurses and providers in intensive care units.

November 28, 2012

Characterising the complexity of medication safety using a human factors approach: an observational study in two intensive care units.

November 6, 2013

Factors contributing to an increase in duplicate medication order errors after CPOE implementation.

August 17, 2011

Medication safety in two intensive care units of a community teaching hospital after electronic health record implementation: sociotechnical and human factors engineering considerations.

March 15, 2017

ICU nurses' acceptance of electronic health records.

July 13, 2011

The effects of computerized provider order entry implementation on communication in intensive care units.

February 20, 2013

FMEA team performance in health care: a qualitative analysis of team member perceptions.

June 24, 2009

A family-centered rounds checklist, family engagement, and patient safety: a randomized trial.

May 31, 2017

Using failure mode and effects analysis to plan implementation of smart i.v. pump technology.

August 23, 2006

Human factors systems approach to healthcare quality and patient safety.

August 14, 2013

Evaluation of nurse interaction with bar code medication administration technology in the work environment.

March 28, 2007

Conducting an efficient proactive risk assessment prior to CPOE implementation in an intensive care unit.

June 13, 2012

Adverse event reporting: harnessing residents to improve patient safety.

November 8, 2017

Are parents who feel the need to watch over their children's care better patient safety partners?

December 6, 2017

Human factors in patient safety as an innovation.

June 2, 2010

Human factors of complex sociotechnical systems.

June 28, 2006

Parent perceptions of children's hospital safety climate.

April 17, 2013

Workarounds to barcode medication administration systems: their occurrences, causes, and threats to patient safety.

May 14, 2008

Burden of difficult encounters in primary care: data from the Minimizing Error, Maximizing Outcomes Study.

March 4, 2009

A systematic review of human factors and ergonomics (HFE)-based healthcare system redesign for quality of care and patient safety.

March 25, 2015

Contributions of tele-intensive care unit (tele-ICU) technology to quality of care and patient safety.

January 23, 2013

A roadmap to advance patient safety in ambulatory care.

January 20, 2021

Application of human factors to improve usability of clinical decision support for diagnostic decision-making: a scenario-based simulation study.

January 8, 2020

From tasks to processes: the case for changing health information technology to improve health care.

April 1, 2009

SEIPS 101 and seven simple SEIPS tools.

June 9, 2021

Exploring performance obstacles of intensive care nurses.

November 19, 2008

A human factors engineering conceptual framework of nursing workload and patient safety in intensive care units.

October 12, 2005

Joy in medical practice: clinician satisfaction in the Healthy Work Place trial.

November 1, 2017

Human factors and ergonomics as a patient safety practice.

July 31, 2013

Quality improvement and patient safety activities in academic departments of medicine.

October 31, 2012

Impact of performance obstacles on intensive care nurses' workload, perceived quality and safety of care, and quality of working life.

April 1, 2009

Strategies for improving family engagement during family-centered rounds.

May 29, 2013

Information chaos in primary care: implications for physician performance and patient safety.

November 30, 2011

State of science: human factors and ergonomics in healthcare.

September 4, 2013

Association of communication between hospital-based physicians and primary care providers with patient outcomes.

January 21, 2009

Care transitions in the outpatient surgery preoperative process: facilitators and obstacles to information flow and their consequences.

November 14, 2007

Perioperative COVID-19 defense: an evidence-based approach for optimization of infection control and operating room management.

April 22, 2020

Where trust flourishes: perceptions of clinicians who trust their organizations and are trusted by their patients.

January 12, 2022

Working conditions in primary care: physician reactions and care quality.

July 22, 2009

What works in medication reconciliation: an on-treatment and site analysis of the MARQUIS2 study.

April 12, 2023

Challenges and opportunities for improving patient safety through human factors and systems engineering.

December 5, 2018

Effects of a refined evidence-based toolkit and mentored implementation on medication reconciliation at 18 hospitals: results of the MARQUIS2 study.

May 19, 2021

A toolkit to disseminate best practices in inpatient medication reconciliation: Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS).

July 31, 2013

Effects of a multifaceted medication reconciliation quality improvement intervention on patient safety: final results of the MARQUIS study.

September 12, 2018

SEIPS 3.0: human-centered design of the patient journey for patient safety.

February 19, 2020

Do work condition interventions affect quality and errors in primary care? Results from the Healthy Work Place Study.

September 28, 2016

A cluster randomized trial of interventions to improve work conditions and clinician burnout in primary care: results from the Healthy Work Place (HWP) study.

January 27, 2016

A multisite study of interprofessional teamwork and collaboration on general medical services.

November 25, 2020

Just what the doctor ordered. Review of the evidence of the impact of computerized physician order entry system on medication errors.

July 11, 2007

Usability of a human factors-based clinical decision support in the emergency department: lessons learned for design and implementation.

May 11, 2022

Family-initiated dialogue about medications during family-centered rounds.

February 11, 2015

Sleep, sleepiness, fatigue, and performance of 12-hour–shift nurses.

August 3, 2016

Meaningful use's benefits and burdens for US family physicians.

May 30, 2018

Sleep deprivation and error in nurses who work the night shift.

February 19, 2014

Polypharmacy in hospitalized older adult cancer patients: experience from a prospective, observational study of an oncology-acute care for elders unit.

August 5, 2009

EHR safety: the way forward to safe and effective systems.

April 2, 2008

Creative education for rapid response team implementation.

March 11, 2009

Parent-reported errors and adverse events in hospitalized children.

March 16, 2016

Parent–provider miscommunications in hospitalized children.

August 23, 2017

SEIPS 2.0: a human factors framework for studying and improving the work of healthcare professionals and patients.

October 3, 2013

Determining current insulin pen use practices and errors in the inpatient setting.

November 30, 2016

Preventing communication errors in telephone medicine.

October 12, 2005

Effect of complementary interventions to redesign care on teamwork and quality for hospitalized medical patients: a pragmatic controlled trial.

November 15, 2023

Self-reported violations during medication administration in two paediatric hospitals.

May 16, 2012

Communication and shared understanding between parents and resident-physicians at night.

July 13, 2016

Barriers and facilitators to injection safety in ambulatory care settings.

August 29, 2018

Compelled disclosure of confidential information in patient safety research.

April 21, 2021

Work system barriers and facilitators of a team health information technology.

September 13, 2023

Medication errors with pediatric liquid acetaminophen after standardization of concentration and packaging improvements.

October 17, 2018

Effect of a systems intervention on the quality and safety of patient handoffs in an internal medicine residency program.

May 15, 2013

Patient safety: break the silence.

May 9, 2012

Hospital-acquired SARS-Cov-2 infections in patients: inevitable conditions or medical malpractice?

February 10, 2021

Professional behavior and value erosion: a qualitative study of physicians and the electronic health record.

November 9, 2022

Redesigning rounds: towards a more purposeful approach to inpatient teaching and learning.

January 14, 2015

Quality of outpatient clinical notes: a stakeholder definition derived through qualitative research.

February 6, 2013

Nurses' experiences of drug administration errors.

October 10, 2007

Developing and implementing new safe practices: voluntary adoption through statewide collaboratives.

August 16, 2006

Frequency, type, and degree of potential harm of adverse safety events among pediatric emergency medical services encounters.

November 1, 2023

Rounding to influence.

September 29, 2010

March 6, 2005

Patient-reported service quality on a medicine unit.

November 30, 2005

What can hospitalized patients tell us about adverse events? Learning from patient-reported incidents.

August 17, 2005

A review of the evidence of harm from self-tests.

September 17, 2014

Patient safety and quality improvement: ethical principles for a regulatory approach to bias in healthcare machine learning.

July 22, 2020

Evaluation of drug interaction software to identify alerts for transplant medications.

March 6, 2005

A descriptive study of nurse-reported missed care in neonatal intensive care units.

May 6, 2015

The effect of documenting patient weight in kilograms on pediatric medication dosing errors in emergency medical services.

May 3, 2023

Attitudes toward medical device use errors and the prevention of adverse events.

November 14, 2007

Application of surgical safety standards to robotic surgery: five principles of ethics for nonmaleficence.

April 2, 2014

The incidence of diagnostic error in medicine.

August 14, 2013

Diagnostic errors in medicine: a case of neglect.

March 6, 2005

From a blame culture to a just culture in health care.

November 18, 2009

SBAR: electronic handoff tool for noncomplicated procedural patients.

January 4, 2012

Disparate perspectives: exploring healthcare professionals' misaligned mental models of older adults' transitions of care between the emergency department and skilled nursing facility.

July 21, 2021

The effects of stress and coping on surgical performance during simulations.

January 13, 2010

Role of pharmacist counseling in preventing adverse drug events after hospitalization.

March 22, 2006

Factors influencing preceptors' responses to medical errors: a factorial survey.

October 19, 2005

CancelRx: a health IT tool to reduce medication discrepancies in the outpatient setting.

September 1, 2021

Blood and blood products transfusion errors: what can we do to improve patient safety.

May 10, 2023

Use of unit-based interventions to improve the quality of care for hospitalized medical patients: a national survey.

August 2, 2017

Related Resources

Patient safety of perioperative medication through the lens of digital health and artificial intelligence.

June 28, 2023

Understanding medication safety involving patient transfer from intensive care to hospital ward: a qualitative sociotechnical factor study.

June 7, 2023

Patient Safety Innovations

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

May 31, 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

Development and pilot evaluation of an electronic health record usability and safety self-assessment tool.

August 24, 2022

Association between limiting the number of open records in a tele-critical care setting and retract-reorder errors.

July 21, 2021

Safer prescribing for hospitalized older adults with an electronic health records‐based prescribing context.

October 28, 2020

WebM&M Cases

Direct Oral Anticoagulants are High-Risk Medications with Potentially Complex Dosing

June 24, 2020

National trends in the safety performance of electronic health record systems from 2009 to 2018.

June 17, 2020

Hidden health IT hazards: a qualitative analysis of clinically meaningful documentation discrepancies at transfer out of the pediatric intensive care unit.

August 28, 2019

Investigating the impact of intensive care unit interruptions on patient safety events and electronic health records use: an observational study.

July 24, 2019

Transcription errors of blood glucose values and insulin errors in an intensive care unit: secondary data analysis toward electronic medical record–glucometer interoperability.

May 29, 2019

What's in a name? Provider perception of injured John Doe patients.

April 3, 2019

Data omission by physician trainees on ICU rounds.

February 6, 2019

Analysis of medication therapy discontinuation orders in new electronic prescriptions and opportunities for implementing CancelRx.

November 14, 2018

Use of a novel, electronic health record–centered, interprofessional ICU rounding simulation to understand latent safety issues.

October 24, 2018

Adverse effects of computers during bedside rounds in a critical care unit.

August 1, 2018

Prospective evaluation of medication-related clinical decision support over-rides in the intensive care unit.

February 28, 2018

Case not closed: prescription errors 12 years after computerized physician order entry implementation.

January 31, 2018

Impact of commercial computerized provider order entry (CPOE) and clinical decision support systems (CDSSs) on medication errors, length of stay, and mortality in intensive care units: a systematic review and meta-analysis.

April 26, 2017

Medication safety in two intensive care units of a community teaching hospital after electronic health record implementation: sociotechnical and human factors engineering considerations.

March 15, 2017

Medication safety in the neonatal intensive care unit: big measures for our smallest patients.

March 8, 2017

WebM&M Cases

Unexpected Drawbacks of Electronic Order Sets

November 1, 2016

Accuracy of laboratory data communication on ICU daily rounds using an electronic health record.

October 12, 2016

Frequency of passive EHR alerts in the ICU: another form of alert fatigue?

July 27, 2016

Ambulatory computerized prescribing and preventable adverse drug events.

June 8, 2016

Rising drug allergy alert overrides in electronic health records: an observational retrospective study of a decade of experience.

December 2, 2015

Draft Guidelines for the Safe Communication of Electronic Medication Information.

September 16, 2015

Effect of a real-time pediatric ICU safety bundle dashboard on quality improvement measures.

September 2, 2015

See More About The Topic

Intensive Care Units

Health Care Executives and Administrators

Information Professionals

Critical Care

Medication Errors/Preventable Adverse Drug Events

EHR-related medication errors in two ICUs.

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

EHR-related medication errors in two ICUs.

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