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Clinicians were oblivious to incorrect logging of test dates and the associated risks in an online pathology application: a case study

Clinicians were oblivious to incorrect logging of test dates and the associated risks in an online pathology application: a case study
Clinicians were oblivious to incorrect logging of test dates and the associated risks in an online pathology application: a case study
Background: UK primary care physicians receive their laboratory test results electronically. This study reports a computerised physician order entry (CPOE) system error in the pathology test request date that went unnoticed in family practices.

Method: We conducted a case study using a causation of risk theoretical framework; comprising interviews with clinicians and the manufacturer to explore the identification of and reaction to the error. The primary outcome was the evolution and recognition of and response to the problem. The secondary outcome was to identify other issues with this system noted by users.

Results: The problem was defined as the incorrect logging of test dates ordered through a CPOE system. The system assigned the test request date to the results, hence a blood test taken after a therapeutic intervention (e.g. an increase in cholesterol-lowering therapy) would appear in the computerised medical record as though it had been tested prior to the increase in treatment. This case demonstrates that: the manufacturers failed to understand family physician workflow; regulation of medical software did not prevent the error; and inherent user trust in technology exacerbated this problem. It took three months before users in two practices independently noted the date errors.

Conclusion: This case illustrates how users take software on trust and suppliers fail to make provision for risks associated with new software. Resulting errors led to inappropriate prescribing, follow-up, costs and risk. The evaluation of such devices should include utilising risk management processes (RMP) to minimise and manage potential risk.
computerised medical records systems, general practice, medical informatics, medical order entry systems, safety management
241-247
Appleton, A.
710fef9b-1c1d-4f83-ae65-6d885e6eaca1
Khaled, S.
f3385791-a86b-4c4a-8e30-2b90f1af8686
Dawson, Ian G.J
dff1b440-6c83-4354-92b6-04809460b01a
de Lusignan, S.
67a36f6c-26a8-450b-9603-ba28bbca01fa
Appleton, A.
710fef9b-1c1d-4f83-ae65-6d885e6eaca1
Khaled, S.
f3385791-a86b-4c4a-8e30-2b90f1af8686
Dawson, Ian G.J
dff1b440-6c83-4354-92b6-04809460b01a
de Lusignan, S.
67a36f6c-26a8-450b-9603-ba28bbca01fa

Appleton, A., Khaled, S., Dawson, Ian G.J and de Lusignan, S. (2012) Clinicians were oblivious to incorrect logging of test dates and the associated risks in an online pathology application: a case study. Informatics in Primary Care, 20 (4), 241-247. (PMID:23890335)

Record type: Article

Abstract

Background: UK primary care physicians receive their laboratory test results electronically. This study reports a computerised physician order entry (CPOE) system error in the pathology test request date that went unnoticed in family practices.

Method: We conducted a case study using a causation of risk theoretical framework; comprising interviews with clinicians and the manufacturer to explore the identification of and reaction to the error. The primary outcome was the evolution and recognition of and response to the problem. The secondary outcome was to identify other issues with this system noted by users.

Results: The problem was defined as the incorrect logging of test dates ordered through a CPOE system. The system assigned the test request date to the results, hence a blood test taken after a therapeutic intervention (e.g. an increase in cholesterol-lowering therapy) would appear in the computerised medical record as though it had been tested prior to the increase in treatment. This case demonstrates that: the manufacturers failed to understand family physician workflow; regulation of medical software did not prevent the error; and inherent user trust in technology exacerbated this problem. It took three months before users in two practices independently noted the date errors.

Conclusion: This case illustrates how users take software on trust and suppliers fail to make provision for risks associated with new software. Resulting errors led to inappropriate prescribing, follow-up, costs and risk. The evaluation of such devices should include utilising risk management processes (RMP) to minimise and manage potential risk.

Full text not available from this repository.

More information

Published date: July 2012
Keywords: computerised medical records systems, general practice, medical informatics, medical order entry systems, safety management
Organisations: Centre of Excellence for International Banking, Finance & Accounting

Identifiers

Local EPrints ID: 361286
URI: https://eprints.soton.ac.uk/id/eprint/361286
PURE UUID: 753d21c4-e324-4e28-81f0-bf596084891b
ORCID for Ian G.J Dawson: ORCID iD orcid.org/0000-0003-0555-9682

Catalogue record

Date deposited: 16 Jan 2014 14:48
Last modified: 12 Nov 2019 01:40

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