. "6 Action Agenda for the Pharmaceutical, Medical Device, and Health Information Technology Industries ." Preventing Medication Errors: Quality Chasm Series. Washington, DC: The National Academies Press, 2007.
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Preventing Medication Errors
Standards Institute (ANSI), and are a part of the FDA’s Good Manufacturing Practices (GMP) regulatory requirements (IOM, 2004). The standards do not go far enough to address user interface issues, however, and additional work is needed.
Medication errors also result from comparable problems in the user interface design for decision-support systems. A recent study of CPOE systems found that human–machine interface flaws facilitated 22 types of medication errors (Koppel et al., 2005).
A number of factors affect the ability of clinicians to interact effectively and efficiently with decision-support systems (whether CPOE, electronic health records, or pharmacy database). First, most of the commercial systems on the market were designed according to rigid machine rules that do not correspond appropriately to the clinician’s workflow and behavior (Koppel et al., 2005). The natural chain of clinical events is disrupted while clinicians are forced to accommodate the rigid data requirements of the technology (Han et al., 2005). Often, a second physician devoted solely to entering orders is needed when time-sensitive therapeutic interventions must be administered, such as in emergency or intensive care. Second, many interface designs are highly impractical or outdated. Information is presented in numerous lines of identical-looking text, without a windows-based structure or intuitive graphical navigation aids (Ash et al., 2004). Even when the information is there, it is difficult to find. Clinicians must click on multiple different screens to either retrieve all of a patient’s information or enter new clinical information. Information becomes fragmented, and clinicians lose their ability to develop a more comprehensive overview and conceptual understanding of the case (Ash et al., 2004). For example, in many inpatient CPOE systems, patient names are grouped alphabetically rather than by clinical staff or rooms. Thus similar names, combined with small fonts, hectic workstations, and interruptions, can easily be confused (Koppel et al., 2005). Equally troubling, a patient’s medication information is seldom synthesized on one screen; a clinician may need to access up to 20 screens to view all the medications included in the patient’s regimen. Although decision-support systems use standard computer monitors to display information, a significant amount of work is needed to develop optimal user interface designs that can make data capture and manipulation easier for clinicians and more accurate for patient safety.
Data presentation and the user interface affect the usability of bar code medication administration systems as well. Although there are no studies indicating that the design of such systems directly caused medication errors (Johnson et al., 2002), several studies have confirmed that negative unintended consequences resulting from the introduction of these systems may