Using an accident model to design safe electronic medication management systems

Studies in Health Technology and Informatics

Volumn 129, Issue , 2007, Pages 948-952

  Magrabi, Farah ^a   McDonnell, Geoff ^a   Westbrook, Johanna I ^b   Coiera, Enrico ^a  

^a UNIVERSITY OF NEW SOUTH WALES   (Australia)

^b UNIVERSITY OF SYDNEY   (Australia)

Author keywords

computer simulation; medical order entry systems; medication errors; safety management; systems theory

Indexed keywords

COMPUTER SIMULATION; ERRORS; SYSTEM THEORY; SYSTEMS ENGINEERING;

DYNAMIC SYSTEMS MODELING; ELECTRONIC MEDICATION MANAGEMENT SYSTEMS; ERROR GENERATION; MEDICAL ORDER ENTRY SYSTEMS; MEDICATION ERRORS; MEDICATION MANAGEMENT; PATTERNS OF FAILURE; SAFETY MANAGEMENT;

ACCIDENTS;

ARTICLE; HOSPITAL INFORMATION SYSTEM; HOSPITAL ORGANIZATION; HUMAN; MEDICATION ERROR; SAFETY; SYSTEM ANALYSIS; SYSTEMS THEORY;

HUMANS; MEDICAL ORDER ENTRY SYSTEMS; MEDICATION ERRORS; MEDICATION SYSTEMS; SAFETY MANAGEMENT; SYSTEMS ANALYSIS; SYSTEMS THEORY;

EID: 35748946370     PISSN: 09269630     EISSN: 18798365     Source Type: Book Series    
DOI: None     Document Type: Conference Paper

References (30)

1. US Institute of Medicine: Crossing the quality chasm: A new health system for the 21st Century. USA: National Academy Sciences Press; 2000
2. National Health Service: Reports by the chief pharmaceutical officer. Building a safer NHS: Improving safety medication. London: National Health Service
3. Leap Frog Group. Computer assisted order entry fact sheet. Washington: Leap Frog Group; 2001
4. Ash JS, Berg M, Coiera E. Some unintended consequences of information technology in health care: the nature of patient care information system-related errors. J Am Med Inform Assoc 2004;11(2):104-12
5. EFMI. Bad Health Informatics Can Kill: Working Group for Assessment of Health Information Systems of the European Federation for Medical Informatics(EFMI): iig. umit. at/ efmi/ [14 Nov 2006]
6. Han YY, Carcillo JA, Venkataraman ST, Clark RS, Watson RS, Nguyen TC, Bayir H, Orr RA. Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system. Pediatrics 2005;116(6):1506-12
7. Gesteland PH, Nebeker JR, Gardner RM. These are the technologies that try men's souls: common-sense health information technology. Pediatrics 2006;117(1):216-7
8. Koppel R, Metlay JP, Cohen A, Abaluck B, Localio AR, Kimmel SE, Strom BL. Role of computerized physician order entry systems in facilitating medication errors. JAMA 2005;293(10):1197-203
9. US Pharmacopeia: MEDMARX 5th Anniversary Data Report: A Chartbook of 2003 Findings and Trends 1999ñ2003; 2004
10. Nebeker JR, Hoffman JM, Weir CR, Bennett CL, Hurdle JF. High rates of adverse drug events in a highly computerized hospital. Arch Intern Med 2005;165(10):1111-6
11. Horsky J, Kuperman GJ, Patel VL. Comprehensive analysis of a medication dosing error related to CPOE. J Am Med Inform Assoc 2005;12(4):377-82
12. Gandhi TK, Weingart SN, Seger AC, Borus J, Burdick E, Poon EG, Leape LL, Bates DW. Outpatient prescribing errors and the impact of computerized prescribing. J Gen Intern Med 2005;20(9):837-41
13. Fox J, Das S. Safe and sound: artificial intelligence in hazardous applications /. California: AAAI Press/MIT Press; 2000
14. Coiera EW, Westbrook JI. Should clinical software be regulated? Med J Aust 2006;184(12):601-2
15. Australian Government Department of Health and Ageing Therapeutic Drugs Administration: www. tga. gov. au/ devices/devices. htm. [cited Oct 24]
16. US Food and Drug Administration: Regulatory Requirements for Medical Devices: www. fda. gov/cdrh/ manual/510kprt1. html. [cited Oct 24]
17. Bar-Yam Y. Making things work: solving complex problems in a complex world. Newton: NECSI-Knowledge Press; 2004
18. Coiera E. Interaction design theory. Int J Med Inform 2003;69(2-3):205-22
19. Berg M. Patient care information systems and health care work: a sociotechnical approach. Int J Med Inform 1999;55(2):87-101
20. Coiera E. Four rules for the reinvention of health care. BMJ 2004;328(7449):1197-9
21. Hollnagel E. Barriers and accident prevention. Aldershot: Ashgate; 2004
22. Dhillon BS. Human reliability and error in medical system. Singapore: World Scintific Publishing; 2003
23. Reason J. Human Error. Cambridge: Cambridge University Press; 1990
24. McDonnell G, Heffernan M. The Dynamics of Hospital Medication Errors: A Systems Simulator Testbed for Patient Safety Interventions. In: 23rd International Conference of The System Dynamics Society July 17-21, Boston. ; 2005
25. Rasmussen J. Risk management in a dynamic society: a modelling problem. Safety Science 1997;27(2/3):183
26. Leveson N. A new accident model for engineering safer systems. Safety Science 2004;42(4):237-270
27. Leveson N. Model-Based Analysis of Socio-Technical Risk: Technical Report, Engineering Systems Division, Massachusetts Institute of Technology. ; 2002 June
28. Sterman JD. Business Dynamics: Systems Thinking and Modeling for a Complex World. Irwin: McGraw-Hill; 2000
29. Bell DS, Cretin S, Marken RS, Landman AB. A conceptual framework for evaluating outpatient electronic prescribing systems based on their functional capabilities. J Am Med Inform Assoc 2004;11(1):60-70
30. Anderson JG, Jay SJ, Anderson M, Hunt TJ. Evaluating the capability of information technology to prevent adverse drug events: a computer simulation approach. J Am Med Inform Assoc 2002;9(5):479-90.