Table 2.

Coding scheme for classification of electronic medication management system (EMM)‐related incidents

ID	Type of health information technology (HIT) related safety concern	Examples
HIT 1	Instances in which HIT fails during use or is otherwise not working as designed	Broken hardware or software ‘bugs’
HIT 2	Instances in which users describe negative experiences with HIT such as stress, frustration, or confusion (revised definition, modified from original (Sittig et al., 2014; ¥)	Users reporting that the system is too difficult to use, or too slow (example added, not in the original (Sittig et al., 2014; ¥)
HIT 3	Instances in which HIT is well designed and working correctly, but was not configured, implemented or used in a way anticipated or planned for by system designers and developers. This includes all incidents of EMM use that would be useful to show designers to inform possible improvements to the EMM system—for example, when the drugs ‘fell off’ the chart	Duplicate order alerts that fire on alternative ‘as needed’ pain medications
HIT 4	Instances in which HIT is working as designed and was configured and used correctly, but interacts with external systems (e.g. via hardware or software interfaces) so that data are lost or incorrectly transmitted or displayed	Medication order for extended‐release morphine inadvertently changed to immediate‐release morphine by error in interface translation table
HIT 5	Instances in which [it is explicitly reported that] specific safety features or functions were not implemented or not available (i.e. HIT could have prevented a safety concern)	Hospitalised patient inadvertently receives 5 g of acetaminophen in 24 hr because maximum daily dose alerting was not available
HIT 0	None of the above (not in original; Sittig et al., 2014)

Scheme adapted from Sittig et al. (2014) classification of incidents with health information technology (HIT). Italics indicate modifications to the original classification. We modified category HIT2, originally intended to cover HIT usability issues, to make more explicit dimensions related to the user experience of EMM (Usability.gov, 2018). We modified category HIT3 inclusion criteria as it was not possible to determine that anticipated or planned for by designers or developers. Instead, we used HIT3 to classify incidents reporting use of EMM that we assessed would be worthwhile for designers to investigate, in order to improve the design of (or the training on) EMM. We modified HIT5, limiting its use to incident reports providing explicit reference to missing features or functionalities. We added a HIT0 ‘other’ type to code any EMM‐related incidents not otherwise captured by the HIT1‐5 categories.

(¥) Original HIT definition: ‘HIT 2: Instances in which HIT is working as designed, but the design does not meet the user's needs or expectations. Examples: Usability issues’ (Sittig et al., 2014).