Table 1. Deconstruction of the 36 incidents analyzed to highlight the usability issues that gave rise to patient safety incidents: the usability flaws, usage problems, and negative outcomes are summarized.
| ID | Usability flaw(s) | Usage problem(s) | Negative outcome(s): patient safety issue(s) |
|---|---|---|---|
| Electronic patient scale | |||
| #242 | A patient scale allowed users to switch easily between units (pounds vs. kilograms) while it is supposed to be kept in kilograms | A nurse did not notice the change and weighed a patient incorrectly. Based on this erroneous measure, (s)he administered the wrong dose of medication | Despite this incident, the patient was not harmed and did not require medical management |
| Imaging system | |||
| #202 | The system merged the incorrect data and rejected the original images: images had the wrong patient tag. No further details were available about the usability flaw | It led to the misidentification of a patient and the surgery (s)he had to undergo | A surgery was performed on the wrong patient. No further details were available about patient outcome |
| #229 | The date of the image was not visible or was missing (not detailed) | The radiologist mistook an old image for a recent one and misdiagnosed the spreading of a metastatic disease | The disease spread widely |
| #163 | The left-right markers of an image were not sufficiently visible | The patient's image was flipped left-right unnoticedly. Based on this image, a surgeon operated on the wrong side | The wrong side of the head of the patient was operated upon |
| #267 | Images supporting the placement of a Peripherally Inserted Central Catheter (PICC) line did not show the line that was inserted too far | A radiologist misunderstood the absence of the line on the image, thought it has been removed and did not check it | This misunderstanding contributed to the death of the baby |
| CPOE/EHR/MAR/PCS | |||
| #42 | A medication was ordered but its prescription was not populated in the administration plan | The medication was administered 3 days late | The patient suffered from an ulcer that required a gastrectomy |
| #92 | A volume less than 0.01 mL was not displayed with the order | The nurse had to calculate the volume to be administered and miscalculated the dose | A patient received almost a 10-fold overdose of insulin by injection |
| #123 | In the drug administration details screen, after a 30 mL bottle of azithromycin 200 mg/5 mL was scanned, the screen displayed 200 mg as the dose amount, and 30 mL as the volume: the volume to administer was incorrect | A clinician miscalculated the dose and administered 1,200 mg of azithromycin instead of 250 mg ordered | The patient received almost five times the ordered dose, but no adverse effect was reported |
| #237 | Manual entries of patient allergies were overwritten during automatic updates | A clinician prescribed a medication ignoring that the patient was allergic | The patient suffered a temporary allergic reaction (shortness of breath) to the medication but had no further effect |
| #239 | A dropdown menu for medication dosing frequency contained 225 options arranged in alphabetical order and included counterintuitively arranged items | A user scrolled through the menu and selected the wrong frequency leading to a dosing error | The patient received four times the expected dose of digoxin |
| #239bis | An update in the frequency field on an existing prescription was not transmitted to the pharmacy: the pharmacy received the order with the wrong frequency | A clinician administered more than the prescribed dose | An elderly patient received more than the ordered dose of blood thinner Levoxyl for 6 weeks but had no serious injury Another patient received inappropriate dosage of carbamazepine and was admitted to hospital with atypical chest pains |
| #247 | The concentration of the medication was displayed amidst extraneous information in small font | A clinician did not see the concentration and made a mistake in the dose administered to a patient | The patient received 10 times the dose of epinephrine ordered and sustained a myocardial infarction (heart attack) |
| #248 | An order to hold the sliding scale insulin at night time was delivered but without notification | A nurse did not see the order and gave the patient the usual dose of insulin | The patient endured hypoglycemia with severe symptoms |
| #249 | A CPOE did not warn about duplicate medications; the font size was small; and the screen contained excess extraneous information | A physician ordered medications twice at different doses and schedules A pharmacist missed the duplicate medications Physicians delivered all medications ordered |
The patient received all the medications ordered. No further details were available about patient outcome |
| #250 | Orders for stress tests were ambiguous and displayed over four lines | A clinician misunderstood the physician's order and gave the patient the incorrect pharmacological modality (i.e., wrong form) | The patient incorrectly received an infusion of adenosine which caused him/her a life-threatening acute asthma attack |
| #251 | To enter a postoperative order, physicians needed to delete orders that were no longer needed, i.e., inactive orders, leave orders that were still needed, and then add new ones. This was a time-consuming and unusual procedure | Clinicians did not always perform this review due to the extra work and time it required. This led to commingling of the pre- and postoperative orders | One patient got his/her clean postoperative abdomen irrigated based on a preoperative order |
| #252 | The interface of a CPOE was unfriendly and displayed extensive extraneous information | A physician did not see an existing order and ordered duplicate treatments for a patient | The patient received duplicate treatments: infusion of total parenteral nutrition and concentrated dextrose solution. Their cumulative dose caused pulmonary edema |
| #257 | A patient was moved to another bed. But the order to transfer the patient was not received by the recipient care team | The recipient care team was not aware that the patient was under their care | The patient had seizures on floor for many hours throughout the night without the care team taking care of him/her |
| #265 | The procedure to reconcile orders with the execution of the orders was complex | A clinician did not execute the order. It was not known that the order was not executed. This led to a missed diagnosis opportunity | A patient with a life-threatening disease was not treated appropriately, contributing to his/her death |
| #266 | On a CPOE interface, the orders were obfuscated by verbiage and the system discontinued them | A clinician missed the orders, and therefore did not execute them | A known consequence is that an order for a transcutaneous pacemaker with life-threatening consequences (no details) failed to be executed |
| #266bis | Once correctly ordered, the system switched doses of methadone syrup for two patients without informing the user | A clinician gave a patient 5 mg more of methadone syrup than initially ordered | The patient received an excess dose of methadone but was not harmed |
| #269 | Test orders (hypercoagulability tests) were spuriously cancelled by the system without notifying ordering physicians | Clinicians did not execute the hypercoagulability tests ordered for a patient having blood clots | The blood clots remained unexplained. No further details were available about patient outcome |
| #270 | The font size of the list of patients was small | A clinician clicked on the wrong patient and entered an order of a test using radioactive tracers | A patient received the radioactive injection intended for another patient |
| #271 | The interface does not specify the dose in mg of a combination medication (e.g., in the Acetaminophen-Oxycodone, the exact dose of Tylenol is not specified). Moreover, certain fields do not specify the volume, requiring users to open a pop-up screen to see this information |
A physician did not know the combination medication dose in the volume (s)he ordered An excessive dose of Acetaminophen-Oxycodone was ordered for a patient Neither the physician, the pharmacist, or the nurse recognized and intercepted this medication error The combination medication was given to the patient |
10 mL of Acetaminophen-Oxycodone was given three times over 4 hours, meaning 1,950 mg of Tylenol were administered in 4 hours to a patient in starvation receiving other medication increasing the effects of Tylenol. The patient developed acute renal failure and died |
| #274 | A screen displayed vital information tinctured with abundant clutter. There was no display of current treatments and what had been recently ordered Moreover, the warning system was insufficient |
A clinician did not see the medications already ordered for the patient and ordered duplicate medications and intravenous fluids. (S)he was not warned by the system At least two intravenous solutions were active simultaneously and given to the patient |
The patient received at least two intravenous fluids that were similar |
| #275 | A system variably changed the schedule of medications ordered daily at two distinct doses to be administered daily at two distinct times. The system scheduled both doses to be administered at the same time | A nurse gave an excessive dose at once and skipped the second dose | All patients treated at the facility were endangered |
| #280 | A system did not transfer an order to discontinue intravenous fluids in a postoperative setting to the task list of the nurse | The nurse did not see the order and continued the intravenous fluids | The patient was overloaded with fluid |
| #284 | A system did not provide an adequate representation of the current medications and orders, nor did it display what other members of the care team had ordered. The decision support module was also defective | Physicians ordered four medications that increased the propensity for bleeding. They were not warned by the decision support system | A patient was simultaneously given enoxaparin, unfractionated heparin, aspirin, and warfarin |
| #287 | A system prevented physicians from ordering medications while another service had opened up the patient record | The physician could not order critical medication immediately. The order was delayed | The patient was in danger. No further details were available about patient outcome |
| #290 | A system did not transmit a transportation order Additionally, the way orders were displayed was excessively lengthy |
An order to transport a patient with a monitor because of a heart risk was not seen and not executed | The patient travelled to at least one test without a monitor |
| #293 | To transfer a patient after surgery, physicians must discontinue orders that are no longer needed. It was a counterintuitive function | The physicians wasted time to perform this procedure leading them to neglect this medication reconciliation A physician ordered medications that were already active, and prescriptions written after an operation contained duplicates and triplicates of five medications with distinct doses |
The patient was in danger. No further details were available about patient outcome |
| #300 | Medication labels for infusion bags that were created by a software labeling system were in a small and uniform font | A nurse mistook two bags. She accidentally hung the bag of norepinephrine instead of the epinephrine one | A patient was almost infused with norepinephrine instead of epinephrine |
| #304 | A system did not prevent preoperative and postoperative orders from being commingled nor from allowing multiple orders and doses of the same medication | Physicians had ordered up to six distinct acetaminophen doses, two distinct vancomycin doses, and two distinct famotidine doses concomitantly with pantoprazole in a postop order | The patient was in danger. No further details were available about patient outcome |
| #305 | The function to discontinue medication orders was not working: the medication orders still appeared in the nurses' administration plan | A physician who was aware of the problem wrote a note to the nurses The nurses did not see the note and continued medications orders as they appear in the MAR: gentamicin was given to three patients despite instructions to discontinue the medication |
Three patients received gentamicin while it was discontinued. No immediate injury occurred |
| #501 | On the order entry screen intended for ancillary orders but not for medication orders, it was mentioned that no allergy information was recorded while there was a historical allergy entry Allergy information from previous visits was not displayed without a specific medical record number |
Not being able to see this information, a physician used this order entry screen to order a medication to which the patient was allergic | The patient received the medication to which (s)he was allergic resulting in an allergic reaction. The patient was discharged within 48 hours |
| #313 | When a patient is transferred from a service to another, the system considered the patient to be discharged and to have a new admission. Therefore, during the stay of the patient in a second service, the system provided results related to the previous services only when a search was made on previous reactions to medications using large date constraints Furthermore, the system did not alert users that the date constraints used to make the search were beyond the range of the “current admission” |
A clinician ordered a patient an infusion of famotidine while the patient had already suffered a reaction to this treatment during her/his “first admission” A patient's relative informed a nurse that famotidine was contraindicated. The nurse searched with large date constraints but did not find any previously infused famotidine |
The patient who was suffering from serious delirium received a medication which had previously resulted in an allergic reaction during her/his previous admission The medication was stopped due the relative's insistence |
Abbreviations: CPOE, computerized physician order entry; EHR, electronic health record; MAR, medication administration record; PCS, pharmacist clinical software.