Clinicians were oblivious to incorrect logging of test dates and the associated risks in an online pathology application: a case study
<p><strong>Background</strong> 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.</p><p>...
| Main Authors: | , , , |
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| Format: | Article |
| Language: | English |
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BCS, The Chartered Institute for IT
2013-09-01
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| Series: | Journal of Innovation in Health Informatics |
| Subjects: | |
| Online Access: | http://hijournal.bcs.org/index.php/jhi/article/view/13 |
| _version_ | 1818480865660895232 |
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| author | Amber Appleton Khaled Sadek Ian GJ Dawson Simon de Lusignan |
| author_facet | Amber Appleton Khaled Sadek Ian GJ Dawson Simon de Lusignan |
| author_sort | Amber Appleton |
| collection | DOAJ |
| description | <p><strong>Background</strong> 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.</p><p><strong>Method</strong> 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.</p><p><strong>Results</strong> 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.</p><p><strong>Conclusion</strong> 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.</p> |
| first_indexed | 2024-12-10T11:27:56Z |
| format | Article |
| id | doaj.art-8586d320363d44dda4aac063eceada25 |
| institution | Directory Open Access Journal |
| issn | 2058-4555 2058-4563 |
| language | English |
| last_indexed | 2024-12-10T11:27:56Z |
| publishDate | 2013-09-01 |
| publisher | BCS, The Chartered Institute for IT |
| record_format | Article |
| series | Journal of Innovation in Health Informatics |
| spelling | doaj.art-8586d320363d44dda4aac063eceada252022-12-22T01:50:41ZengBCS, The Chartered Institute for ITJournal of Innovation in Health Informatics2058-45552058-45632013-09-0120424124710.14236/jhi.v20i4.134Clinicians were oblivious to incorrect logging of test dates and the associated risks in an online pathology application: a case studyAmber Appleton0Khaled Sadek1Ian GJ Dawson2Simon de Lusignan3Department of Health Care Management and Policy, University of Surrey, GuildfordDepartment of Health Care Management and Policy, University of Surrey, Guildford,Lecturer in Risk Management, Southampton Management School, University of Southampton,Department of Health Care Management and Policy, University of Surrey, Guildford<p><strong>Background</strong> 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.</p><p><strong>Method</strong> 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.</p><p><strong>Results</strong> 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.</p><p><strong>Conclusion</strong> 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.</p>http://hijournal.bcs.org/index.php/jhi/article/view/13computerised medical records systemsgeneral practicemedical informaticsmedical order entry systemssafety management |
| spellingShingle | Amber Appleton Khaled Sadek Ian GJ Dawson Simon de Lusignan Clinicians were oblivious to incorrect logging of test dates and the associated risks in an online pathology application: a case study Journal of Innovation in Health Informatics computerised medical records systems general practice medical informatics medical order entry systems safety management |
| title | Clinicians were oblivious to incorrect logging of test dates and the associated risks in an online pathology application: a case study |
| title_full | Clinicians were oblivious to incorrect logging of test dates and the associated risks in an online pathology application: a case study |
| title_fullStr | Clinicians were oblivious to incorrect logging of test dates and the associated risks in an online pathology application: a case study |
| title_full_unstemmed | Clinicians were oblivious to incorrect logging of test dates and the associated risks in an online pathology application: a case study |
| title_short | Clinicians were oblivious to incorrect logging of test dates and the associated risks in an online pathology application: a case study |
| title_sort | clinicians were oblivious to incorrect logging of test dates and the associated risks in an online pathology application a case study |
| topic | computerised medical records systems general practice medical informatics medical order entry systems safety management |
| url | http://hijournal.bcs.org/index.php/jhi/article/view/13 |
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