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Medication Safety in Two Intensive Care Units of a Community Teaching Hospital After Electronic Health Record Implementation: Sociotechnical and Human Factors Engineering Considerations

Carayon, Pascale*†; Wetterneck, Tosha, B.*†‡; Cartmill, Randi§; Blosky, Mary, Ann; Brown, Roger*∥; Hoonakker, Peter*; Kim, Robert**; Kukreja, Sandeep††; Johnson, Mark‡‡; Paris, Bonnie, L.§§; Wood, Kenneth, E.∥∥; Walker, James, M.¶¶

doi: 10.1097/PTS.0000000000000358
Original Article: PDF Only

Objective The aim of the study was to assess the impact of Electronic Health Record (EHR) implementation on medication safety in two intensive care units (ICUs).

Methods Using a prospective pre-post design, we assessed 1254 consecutive admissions to two ICUs before and after an EHR implementation. Each medication event was evaluated with regard to medication error (error type, medication-management stage) and impact on patient (severity of potential or actual harm).

Results We identified 4063 medication-related events either pre-implementation (2074 events) or post-implementation (1989 events). Although the overall potential for harm due to medication errors decreased post-implementation only 2 of the 3 error rates were significantly lower post-implementation. After EHR implementation, we observed reductions in rates of medication errors per admission at the stages of transcription (0.13–0, P < 0.001), dispensing (0.49–0.16, P < 0.001), and administration (0.83–0.56, P = 0.011). Within the ordering stage, 4 error types decreased post-implementation (orders with omitted information, error-prone abbreviations, illegible orders, failure to renew orders) and 4 error types increased post-implementation (orders of wrong drug, orders containing a wrong start or stop time, duplicate orders, orders with inappropriate or wrong information). Within the administration stage, we observed a reduction of late administrations and increases in omitted administrations and incorrect documentation.

Conclusions Electronic Health Record implementation in two ICUs was associated with both improvement and worsening in rates of specific error types. Further safety improvements require a nuanced understanding of how various error types are influenced by the technology and the sociotechnical work system of the technology implementation. Recommendations based on human factors engineering principles are provided for reducing medication errors.

From the *Center for Quality and Productivity Improvement, †Department of Industrial and Systems Engineering, University of Wisconsin-Madison; Departments of ‡Medicine and §Surgery, University of Wisconsin School of Medicine and Public Health; ∥University of Wisconsin School of Nursing, Madison, Wisconsin; ¶Formerly at Geisinger Health System, Danville, Pennsylvania; **Oregon Pulmonary Associates, Tualatin, Oregon; ††Franciscan Saint Francis Health System, Indianapolis, Indiana; ‡‡University of Illinois at Urbana-Champaign; §§University of Illinois College of Medicine at Peoria, Illinois; ∥∥University of Maryland, College Park, Maryland; and ¶¶Independent consultant, Harrisburg, Pennsylvania.

Correspondence: Pascale Carayon, PhD, Department of Industrial and Systems Engineering, Center for Quality and Productivity Improvement, University of Wisconsin-Madison, 3126 Engineering Centers Bldg, 1550 Engineering Dr, Madison, WI 53706 (e-mail:

The authors disclose no conflict of interest.

This research was made possible by funding from the Agency for Healthcare Research and Quality (AHRQ; Grant Number R01 HS15274; principal investigator [PI], P.C.). This publication was also supported by the Clinical and Translational Science Award program, previously through the National Center for Research Resources (Grant Number 1UL1RR025011) and now by the National Center for Advancing Translational Sciences (Grant Number 9U54TR000021). Involvement of T.B.W. in the study was partially supported by a NIH/NCCR Clinical Scholar Research Award (K12 RR017614-01). Studies of B.P. were partially funded by the University of Wisconsin-Madison Graduate Engineering Research Scholars program, AHRQ T32 Training Grant 5T32 HS000083-10 (PI, M.S.), and NIH Grant Number R25 GM083252 for the TEAM-Science program of the UW Center for Women's Health Research (PI, M.C.). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH or AHRQ.

The sponsor had no role in the design and conduct of the study, in the collection, analysis, and interpretation of the data, or in the preparation, review, or approval of the article.

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