Running head: EHR MEDICATION ERRORS 1

The Health Care Technology Hazard of Medication Errors from Dose Timing Discrepancies in

Electronic Health Records

Nina Naples

University of San Diego

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The Health Care Technology Hazard of Medication Errors from Dose Timing Discrepancies in

Electronic Health Records

The health care industry is continuing to evolve and revolutionize new technology to

improve patient safety and quality of care. As health information technology advances there are

many variables that have the potential to negatively affect the patient’s safety. One of the

identified top ten health care technology hazards is medication errors from dose timing

discrepancies in electronic health records (EHR) (“Top Ten Health Technology Hazards,” 2019).

According to Bresnick (2017), almost 70 percent of all medication errors get to the patient, with

about one third of mistakes happening during the administration process.

The present order of the medication errors from dose timing discrepancies in EHRs

happens between when the prescriber enters the dose administration time and the time specified

within the EHRs automatically generated worklist (“Top Ten Health Technology Hazards,”

2019). This is a problem because these errors can cause the patient to have missed or delayed

medication doses, which affects their treatment and quality of care. These errors can have

significant clinical implications to the patient if he or she is in critical condition (“Top Ten

Health Technology Hazards,” 2019). While electronic health record systems are considered

innovative health care technology, the combination of configuration and usability issues within

the EHR can contribute to the dose timing discrepancies (“Top Ten Health Technology

Hazards,” 2019).

The purpose of this paper is to identify the issues in the health care technology hazard for

medication errors from dose timing discrepancies in electronic health records and provide a

solution to prevent these errors from happening. It is important to explore this technology hazard

because finding a solution can enhance patient safety and quality of care. By implementing a
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notification of the scheduled medication administration time during the EHR order entry process,

it would allow the prescriber to easily modify the time (“Top Ten Health Technology Hazards,”

2019). Therefore, exploring the option to design the EHR interface to be more user friendly and

intuitive could lessen the amount of errors (Bresnick, 2017).

Literature Review

The search strategy yielded information on solutions for the technology hazard of

medication errors from dose timing discrepancies in electronic health records (EHRs). The

solutions provided throughout each study allows health care providers to prevent medication

errors from happening and improve their processes. Implementing these enhancements will also

increase patient safety and quality of care.

Computerized provider order entry systems with clinical decision support has become

widespread as health organizations adopt and implement electronic health records. The clinical

decision support technology allows for delivering medication related alerts used at the point of

prescription and for verifying a medication to improve patient care (Bhakta et al., 2019). The

downside of these systems are that they are deployed without customization to the organization

(Bhakta et al., 2019). Implementing a system with basic decision support from commercial

knowledge databases can result in many alerts that are not applicable to the specific health

organization (Bhakta et al., 2019). Having a large number of inconsequential alerts can trigger

alert fatigue which causes irritability or exhaustion from the overuse of alerts (Bhakta et al.,

2019). The number of irrelevant alerts can also result in the user ignoring some or all of the

clinical decision support alerts which reduces the effectiveness of patient safety (Bhakta et al.,

2019). By customizing and reducing the alert volume, the study showed a significant increase in

responses to important alerts (Bhakta et al., 2019). While some organizations may be hesitant to
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customize the basic decision support alerts, the overall result of this study showed the

customization increased the percentage of alerts being acknowledged and modified which results

in increased patient safety (Bhakta et al., 2019)

The implementation of electronic health records has reduced the amounts of medication

errors and adverse drug events in patients in intensive care units (Abraham et al., 2017).

However, dosing errors and omissions of required medications have increased after

implementing EHRs (Abraham et al., 2017). This study sought to compare the number of

medication errors and severity of the errors before and after EHR implementation during four

periods over two years (Abraham et al., 2017). The research resulted in an immediate increase in

medication errors after implementing EHR systems, but a reduction in more severe errors

(Abraham et al., 2017). Although there was an immediate increase after implementation, the

overall medication errors reduced after two years (Abraham et al., 2017). The study also found

that the most common source of errors was from prescribing errors and administration errors.

One of the main reasons for the initial increase in medication errors was due to the organization’s

lack of familiarity with the new system and the increased detectability of the systems electronic

timing of drug administration instead of nurse charting (Abraham et al., 2017). The results

showing a reduction in medication errors after two years was primarily due to the improvement

in the implementation process and awareness of the implementation challenges (Abraham et al.,

2017). One solution to these challenges over the two-year period was to change how the

organization trained their employees by providing online and classroom trainings (Abraham et

al., 2017). Another solution was to have readily available technical support, this included

specially trained nurses, pharmacists and physicians who could assist users in real time, instead

of technicians who are not familiar with the organization’s workflow needs (Abraham et al.,
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2017). The study taking two years to see a significant reduction in medication errors proves the

need for a constant, multidisciplinary evaluation of EHR systems to optimize its use (Abraham et

al., 2017).

Medication reconciliation has also been identified as an important intervention to limit

the amount of medication discrepancies (Abebe, 2016). This study reviewed the impact of

electronic medication reconciliation interventions for medication errors during hospital

transitions (Abebe, 2016). Medication discrepancies often occur during transition of care when

patients are admitted or discharged from a hospital (Abebe, 2016). These hospital transitions are

responsible for over half of medication errors (Abebe, 2016). The medication discrepancies

were outlined as one or more difference in dosage, frequency, drug, and route of administration

(Abebe, 2016). The most prevalent medication error was drug omissions (Abebe, 2016). The

study found that implementing electronic medication reconciliation technology greatly reduced

the number of incidences in unintentional medication discrepancies by alerting the prescriber

(Abebe, 2016). Ideally the research stated that a computerized physician order entry program

paired with an electronic medication reconciliation tool, computerized reminder alert, process re-

design and staff training could bridge the gaps in continuity of patient care (Abebe, 2016).This

technological solution has been recognized as an important approach to improve the use of

medication and patients quality of care (Abebe, 2016).

Medication errors can be a significant and common issue when patients are transitioning

between providers (Hopcroft et al., 2018). Conducting a patient centered approach has reduced

medication discrepancies, since the patient is the one constant when transitioning providers

(Hopcroft et al., 2018). This study describes how e-prescribing in electronic medication

management systems can enhance patient safety and quality by ensuring complete and legible
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orders (Hopcroft et al., 2018). Although there are enhancements when using electronic

medication managements systems, there can also be new technological errors such as incorrect

selection of medicines from drop down menus (Hopcroft et al., 2018). The research suggests a

few solutions to improve medication errors by integrating other systems to provide clinical

decision support and a way to easily exchange patient data between providers (Hopcroft et al.,

2018). These systems must be able to ensure that medication selection processes are safe by

providing warnings if a medicine is contraindicated or if a medicine is similar to another’s name,

or if dosing is possibly harmful (Hopcroft et al., 2018). Another solution is to prioritize the

warnings, so they are not ignored (Hopcroft et al., 2018). Health care organizations should

implement these solutions to see improvements in patient safety and quality of care.

Identified Solution

The technology hazard of medication errors from dose timing discrepancies in electronic

health records can have negative effects on patient safety. While there are many solutions

available for health care organizations to consider, the best solution based on the research is to

implement a computerized provider order entry system with customized clinical decision support

and medication reconciliation. This solution allows health care organizations to customize their

clinical decision support tool to decrease the number of irrelevant medication alerts to the

provider (Bhakta et al., 2019).

A large number of irrelevant alerts can lead to alert fatigue which can cause the provider

to ignore some or all of the clinical decision support alerts (Bhakta et al., 2019). The

effectiveness of the alerts for patient safety is then reduced and could potentially cause harm to

the patient (Bhakta et al., 2019). After customizing the clinical decision support tool, the research

showed a substantial increase in provider’s response to alerts (Bhakta et al., 2019). Implementing
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an electronic medication reconciliation tool can also greatly reduce the number of medication

discrepancies (Abebe, 2016). This tool uses alerts to notify the prescriber of a medication

discrepancy (Abebe, 2016). Ideally the health care organization would implement both a

customized clinical decision support tool and medication reconciliation tool with their

computerized physician order entry system (Abebe, 2016). While it could be costly for the health

care organization initially, it would significantly benefit providers workflow within the electronic

health record. Overall, this solution is considered the best option because it increases patient

safety and quality of care.

Prior to integration and implementation of the solution, a failure mode and effect analysis

(FMEA) was undertaken. First, the sequential steps of the solution were visually depicted in a

process map (Appendix A). Second, potential errors were identified (Appendix B). Lastly, a

FMEA was conducted to identify actions for eliminating or controlling the potential causes of

error (Appendix C).

Failure Mode Effect Analysis

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Quality Measure

The quality and safety measures monitored for patient care are critical for analyzing the

technology hazard of medication errors from dose timing discrepancies in electronic health

records. Health care organizations should consider the solution based on this research to

implement a computerized provider order entry system with customized clinical decision support

and medication reconciliation. This solution gives health care organizations the opportunity to

customize their clinical decision support tool which can lead to limiting the number of irrelevant

medication alerts and errors (Bhakta et al., 2019).

This solution requires an outcome quality measure to reduce the medication errors from

dose timing discrepancies in electronic health records. Outcome measures are used to quantify

the health status of patients after they have received their health care (Fondahn, Lane &

Vannucci, 2016). Medication errors have the potential to cause severely negative effects during

patient care.

The quality management team will take ownership of monitoring and measuring the

solution’s outcome and if it was successful in reducing the number of medication errors. The

quality management team will measure the effectiveness of the outcome by utilizing the

reporting and tracking features of the computerized provider order entry system with customized

clinical decision support and medication reconciliation. The team will be able to analyze how

and when medication errors from dose timing discrepancies in electronic health records occur.

The quality management team will analyze the outcome measurement data on the first of every

month and provide a report to the leadership team. This data will provide the health care

organization with more knowledge on how to eliminate medication errors from dose timing

discrepancies.
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Conclusion

The health care industry has a large focus on improving the quality and safety of patients.

One of the health care technology hazards is medication errors from dose timing discrepancies in

electronic health records. Heath care organizations can improve this technology hazard by

implementing a computerized provider order entry system with customized clinical decision

support and medication reconciliation. The failure mode effects analysis shows that the solution

is effective for health care organizations to implement if they do enough research on their

implementation cost, needs, and training. If all health care organizations were required to

implement an improved computerized provider order entry system with customized clinical

decision support and medication reconciliation, there could be a significant decrease in

medication errors from dose timing discrepancies in electronic health records.

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References

Abebe, T. B., Brien, J. E., McLachlan, A. J., and Medkonnen, A. B. (2016). Impact of Electronic

Medication Reconciliation Interventions on Medication Discrepancies at Hospital

Transitions: a Systematic Review and Meta-Analysis. BMC Medical Informatics and

Decision Making 16(112), 1-14. Retrieved from https://doi.org/10.1186/s12911-016-

0353-9

Abraham, P., DiPlotti, C., Han, J. E., Honig, E., Liao, T. V., Martin, G. S., Perez, S., and

Rabinovich, M. (2017). Evaluation of Medication Errors with Implementation of

Electronic Health Record Technology in the Medical Intensive Care Unit. Dove Press

Journal: Open Access Journal of Clinical Trials, 71(9), 31-40. Retrieved from

http://dx.doi.org/10.2147/OAJCT.S13

Bhakta, S. B., Colavecchia, A. C., Haines, L., Varkey, D., & Garney, K. W. (2019). A systematic

Approach to Optimize Electronic Health Record Medication Alerts in a Health System.

American Society of Health-system Pharmacists, 76(8), 530-535. doi:

10.1093/ajhp/zxz012

Bresnick, J. (2017). Patient Safety Errors are Common with Electronic Health Record Use.

Retrieved from https://healthitanalytics.com/news/patient-safety-errors-are-common-

with-electronic-health-record-use

Fondahn, E., Lane, M., & Vannucci, A. (2016). The Washington Manual of Patient Safety and

Quality Improvement. Wolters Kluwer.

Hopcroft, D., Scahill, S., Stapleton, H., & Wheeler, A. J. (2018). Reducing Medication Errors at

Transitions of Care is Everyone’s Business. Australian Prescriber, 41(3), 73-77.

Retrieved from https://doi.org/10.18773/austprescr.2018.021

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Top Ten Health Technology Hazards for 2020. (2019) ECRI Institute. Retrieved from

www.ecri.org/2020hazards
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Appendix A

Process Map
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Appendix B

Potential Errors Associated with the Solution

1 2 3 4 5

Initiate Review of Design Plan for Train All Staff on Implement Confirm
Necessity for Implementation New Electronic Electronic Implementation
Implementation Process Tools Tools is Maintainable
for the
Organization

The organization Underestimate the Inefficient training System defects Undervalue the
Potential
Errors

does not support cost for materials for staff causing delays in need for IT
the cost implementation implementation support

Leadership does Misjudge the Not enough Project leaders Organization

not support the organizations training times did not develop a does not
large change effort readiness for scheduled to plan for a phased regularly update
implementation accommodate staff transition the system
approach

Leadership and Miscalculate the Underestimate the Staff does not Organization
staff do not think amount of time number of qualified have the does not provide
the defined for trainers to support appropriate refresher
problems are implementation staff training and trainings courses
enough to cannot for staff
rationalize new effectively
tools manage patient’s
medications
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Appendix C

Failure Mode Effects Analysis (FMEA)

1 Process Initiate Review of Necessity for Implementation

Step
2 Potential The organization does not support the cost Leadership does not support the large change effort Leadership and staff do not think the defined
Failure problems are enough to rationalize new tools
Mode
3 Potential -Organization does not believe that the initial cost -Organization does not have enough resources to -Organization does not have a strong case for the
Cause(s) will improve the future cost efficiencies accommodate the change new tools
-Organization does not have enough money for the -Leadership is not engaged in change effort to encourage -Organization does not have problems clearly
initial cost of implementation and promote change within the organization defined to strategize and justify new tools
4 Severity 4 4 4
Process Step #1

5 Probability Frequent Frequent Frequent

6 Hazard 8 8 8
Score
7 Action Eliminate Eliminate Eliminate
(Eliminate,
Control, or
Accept)
8 Description -Research and provide evidence-based data to -Research and provide evidence-based data to support the -Create a strategy team to review the identified
of Action justify the potential for future cost efficiencies need for the new tools to improve patient safety problems
-Review the overall budget of necessary -Improve organizational culture to have increased open -Review internal quality management and safety
improvements and reevaluate where necessary, and engaging communication by utilizing suggestion boxes data to clearly identify problems
including other organizational projects and openly discussions about change in divisional meetings -Research and provide evidence-based data to
-Research and provide evidence-based data to -Review list of necessary resources with leadership to support the need for the new tools to improve
support the need for the new tools to improve ensure the organization has the appropriate amount patient safety
patient safety
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1 Process Design Plan for Implementation Process

Step
2 Potential Underestimate the cost for implementation Misjudge the organizations readiness for implementation Miscalculate the amount of time for implementation
Failure
Mode
3 Potential -Underestimate costs in initial budget from not -Misinterpret the internal impacts the organization will -Underestimated the timeline for implementation
Cause(s) clearly outlining each step of implementation and have during implementation -Organization did not take into consideration the
resources needed -Misunderstanding organizational impacts across different potential for system defects
-Underestimate budget due to unforeseen costs departments
during implementation (i.e. system defects)
4 Severity 4 4 4
Process Step #2

5 Probability Frequent Frequent Frequent

6 Hazard 8 8 8
Score
7 Action Eliminate Eliminate Eliminate
(Eliminate,
Control, or
Accept)
8 Description -Create a clear implementation plan to outline the -Conduct a survey across departments to better -Review implementation timelines and plans from
of Action entire process to account for the budget understand each department’s readiness organizations with similar processes and resources
-Review and update budget plan with leadership -Create a process map for each department to visualize -Include time to account for system defects within
before implementation begins impact the implementation timeline
-Continuously review budget throughout -Improve organizational culture to have increased open -Continuously review timeline throughout
implementation to stay on track and adjust if and engaging communication by utilizing suggestion boxes implementation to stay on track and adjust if
necessary, to accommodate for unforeseen costs and openly discussions about change in divisional meetings necessary
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1 Process Train All Staff on New Electronic Tools

Step
2 Potential Inefficient training materials for staff Not enough training times scheduled to accommodate staff Underestimate the number of qualified trainers to
Failure support staff
Mode
3 Potential -Materials are not descriptive enough -Inadequate staff scheduling process -Incorrect number of staff members who need
Cause(s) -Lack of understanding materials from staff -Different departments are available at different times training
-Materials were unclear of the impacts per each -Scheduled training was not long enough to get through -Trainers do not have the correct qualifications and
department the materials skill sets to conduct training
-Trainers were unfamiliar with implementation
materials
Process Step #3

4 Severity 4 4 4

5 Probability Frequent Frequent Frequent

6 Hazard 8 8 8
Score
7 Action Eliminate Eliminate Eliminate
(Eliminate,
Control, or
Accept)
8 Description -Review sample training materials provided by the -Conduct a test training class to determine length and -Review list of resources, including impacted staff
of Action company staff’s level of understanding of implementation members
-Conduct a test training class to determine staff’s -Review scheduling processes with leadership to determine -Ensure all identified trainers have initial
level of understanding of implementation best way to accommodate staff requirements met before conducting a training class
-Create workflows for each department to show -Review training times and scheduling from organizations -Review implementation training guides and
impacts from implementation with similar processes and resources requirements
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1 Process Implement Electronic Tools

Step
2 Potential System defects causing delays in implementation Project leaders did not develop a plan for a phased Staff does not have the appropriate training and
Failure transition approach cannot effectively manage patient’s medications
Mode
3 Potential -IT missed an enhancement during implementation -Project leaders are inexperienced on large -Training materials and classes were not effective
Cause(s) process implementations -Staff missed training classes (new employee’s, staff
-IT coded the program incorrectly -Upper management did not promote a phased transition on PTO, contracted employees)
-IT misunderstood the business needs and timeline approach
for implementation
4 Severity 4 4 4
Process Step #4

5 Probability Frequent Frequent Frequent

6 Hazard 8 8 8
Score
7 Action Eliminate Eliminate Eliminate
(Eliminate,
Control, or
Accept)
8 Description -Develop detailed technical workflows and process -Review different approaches during planning meetings -Schedule make up training classes for those who
of Action maps with project leaders and upper management missed training
-Create requirements documents to clearly outline -Create detailed phased transition documentation for -Review sample training materials provided by the
all enhancements implementation company
-Use an agile approach to implement the new - Review implementation approaches from organizations -Conduct a test training class to determine staff’s
electronic tools to better collaborate with similar processes and resources level of understanding of implementation
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1 Process Confirm Implementation is Maintainable for the Organization

Step
2 Potential Undervalue the need for IT support Organization does not regularly update the system Organization does not provide refresher trainings
Failure courses for staff
Mode
3 Potential -No way to track levels or needs for IT support -No policies requiring updates be implemented -Leadership does not requiring yearly trainings
Cause(s) -Discourage utilizing IT support -No requirements that penalize for not updating the -Staff feels the initial training was enough
-No protocols on how to reach IT support system

4 Severity 4 4 4
Process Step #5

5 Probability Frequent Frequent Occasional

6 Hazard 8 8 6
Score
7 Action Eliminate Eliminate Eliminate
(Eliminate,
Control, or
Accept)
8 Description -Create reports that track the use of IT support -Establish service level agreements (SLA) to ensure the -Create policies that require yearly trainings for all
of Action -Develop open communication avenues between IT system is updated staff members to stay up to date on enhancements
and health professionals to enhance support -Create policies requiring updates when necessary and use of the new tools
-Establish protocols for when IT support is needed -Require sign off on system updates to ensure they are -Create checklists for use of the tools to ensure staff
implemented compliance
-Conduct random audits to ensure training is
effective