Use it or lose it: The role user unfamiliarity with electronic medication systems plays in medication errors

Madaline Kinlay, Wu Yi Zheng, Rosemary Burke, Ilona Juraskova, Lai Mun (Rebecca) Ho, Hannah Turton, Jason Trinh, Melissa Baysari

Background: Electronic medication management (EMM) improve medication safety, but simultaneously introduce new system-related errors, errors highly unlikely with the use of paper records. Limited research has examined how these errors change over time and whether errors related to user unfamiliarity with EMM decrease over time.

Aims: To explore if and how incident reports of system-related errors related to user unfamiliarity with EMM change over time.

Methods: EMM-related incidents occurring at three hospitals in a Local Health District between 1 January 2010 and 31 December 2019 were extracted from the NSW Health Incident Information Management System. Each hospital had introduced the EMM at different time points (one, three and 12 years prior). Factors contributing to these EMM-related incidents were extracted and classified, including user ‘misunderstanding or unfamiliarity with EMM or EMM workflow’ and ‘inadequate training or education’.

Results: The number of incident reports related to user unfamiliarity or inadequate training fluctuated over time but never dissipated. After hospital-wide EMM implementation, user unfamiliarity and inadequate training were associated with at least 20% of incidents every year (range 20% – 86% incidents per year) and were still contributing to 41% of reported incidents during one year in the hospital that had had EMM in place for over 12 years.

Conclusions: EMM systems become more embedded in hospitals with long-term use, but our results indicate that user unfamiliarity with the system is an ongoing issue, despite long-term use. This result highlights that EMM are not set-and-forget systems. Organisations are required to provide ongoing training for new/rotating staff and refresher training with the addition of new system functionalities.