The University of Sydney, Australia.
University of Technology Sydney, Australia.
Stud Health Technol Inform. 2023 Jun 22;304:57-61. doi: 10.3233/SHTI230369.
Electronic medication management systems (EMMS) have been implemented in most acute care settings in Australia to reduce medication error rates. One of the key challenges related to the introduction of EMMS in hospitals is the uptake of informal "workarounds" by clinicians, including nurses. In this study, we aimed to examine one workaround in depth, nurses not documenting medication administration in the EMMS at the time of administration. We conducted a review of incident reports to identify the factors that contribute to this workaround occurring and the consequences or potential consequences of this workaround on patients. We identified a range of contributing factors, with factors relating to the user (e.g. nurses being time poor) occurring most frequently in incident reports. The most frequently seen consequence of this workaround was the patient receiving an additional dose. This research revealed that strategies to reduce the uptake of this workaround should consider user and organisational factors rather than just EMMS design alone.
电子医嘱管理系统（EMMS）已在澳大利亚大多数急症护理环境中实施，以降低用药错误率。在医院引入 EMMS 相关的一个关键挑战是临床医生（包括护士）采用非正规的“临时措施”。在这项研究中，我们旨在深入研究一种临时措施，即护士在给药时不在 EMMS 中记录给药情况。我们对不良事件报告进行了审查，以确定导致这种临时措施发生的因素，以及这种临时措施对患者的后果或潜在后果。我们确定了一系列促成因素，其中与用户相关的因素（例如护士时间紧迫）在不良事件报告中最常出现。这种临时措施最常见的后果是患者额外接受一剂药物。这项研究表明，减少采用这种临时措施的策略应考虑用户和组织因素，而不仅仅是 EMMS 设计本身。
