A Lean Approach to Evaluating Prescribing Errors in Medication Reconciliation

Abstract

We evaluated medication reconciliation processes of a qualitative case study at a 1000-bed public hospital. Lean tools were applied to identify factors contributing to prescribing errors and propose process improvement. Errors were attributed to the prescriber’s skills, high workload, staff shortage, poor user attitude and rigid system function. Continuous evaluation of medication reconciliation efficiency is imperative to identify and mitigate errors and increase patient safety.

Evaluating health information systems-related errors using the human, organization, process, technology-fit (HOPT-fit) framework

“…2 Possible risks of HIS use are alert fatigue (leads to ignored warnings and reminders), 43,64,65 automation bias (complies with system instructions although they are against clinical practice), misuse of copy-and-paste functions, and workarounds for inconvenient or inefficient system functions. 1,66 Ash et al 28 categorized two broad error types: (1) data entry and retrieval, and (2) communication and coordination. Cheung et al 27 classified IT-related incidents as follows: (1) the principal source of IT-related problem: machine-related error (input-output transfer) or human-machine interaction-related (input-output) error; (2) nature of the error (problem): input (data entry), output (data retrieval), and transfer (data transfer between systems); (3) IT systems; and (4) IT problems in the medication process.…”