Table 2.
Coding of the identified incidents related to electronic prescriptions and their short description of the core issues.
| Incident report no. | Human/use-related issue | Machine (technical) related issue | Software (technical) related issue | Short description of the core issues |
|---|---|---|---|---|
| IR1 | Wrong entry or retrieval | Healthcare staff incorrectly deleted patient information about blood pressure medication resulting in the wrong medication for patients | ||
| IR2 | Wrong output | Interface with other software systems or components | The lack of a link between the medication list in EMR and the National prescription repository caused significant risks to patient safety | |
| IR3 | Delayed output | Interface with other software systems or components | Lack of coordination between the clinical care support (administrative) system and the e-prescribing system led to the manual work of the healthcare staff | |
| IR4 | Delayed output | System configuration | The system is not designed to cancel the old prescriptions resulting in patients inadvertently continuing with non-current drugs | |
| IR5 | Did not enter or retrieve | Wrong output | System configuration | The list of old medicines was not set up in a way that it became automatically cancelled when new medicines were prescribed for the patient, which created confusion for the staff |
| IR6 | No output | Software functionality | Faulty software did not transfer sickness certificates and messages related to patient medication affecting patient documentation | |
| IR7 | Wrong output | Software functionality | Electronic prescriptions went wrong for renewed prescriptions due to functional errors resulting in confusion and frustrations among staff | |
| IR8 | No output | Software functionality | Information about patient medication from the medical record disappeared because of software malfunction, causing delays in patient treatment | |
| IR9 | No output | Software functionality | A number of prescriptions for inpatient care have disappeared for three patients (system dysfunction), affecting multiple patients’ care management | |
| IR10 | Wrong entry or retrieval | An incorrect end date was given for the automatic drug dispensing, resulting in delays in the care delivery | ||
| IR11 | Delayed output | Software functionality | A software function in X (a system for patient care documents, including prescriptions) caused delays in message transfer and therefore delay in patient care | |
| IR12 | Delayed output | System configuration | The ‘benefit terms’ were not set up to be displayed in the new version of the application of the pharmaceutical module resulting in an additional workload for the healthcare professionals | |
| IR13 | Wrong output | System configuration | Prescription and administration (within the hospital) views were separate. Physicians and pharmacists did not have the same view leading to staff confusion | |
| IR14 | Partial output | Interface with other software systems or components | Patient change in the Care Portal did not coordinate with the current patient displayed in the pharmaceutical module, causing delays in patient treatment | |
| IR15 | No Output | Data storage & back-up | Prescriptions were missing from the mini-backup affecting the entire organisation, including health IT staff, and the quality of healthcare | |
| IR16 | Did not enter or retrieve | No output | Interface with other software systems or components | Thirty medical prescriptions were not sent from one system to another. 13 of these marked the warning message and disapproved of the prescription. The remaining 17 did not interpret the message correctly, causing risks to patient safety |
| IR17 | System configuration | The root cause of the error was that the system was not configured according to instructions, creating the risk of incorrect dosing of the drugs | ||
| IR18 | Partial output | Interface with other software systems or components | Patient change in the Care Portal did not correspond to the current patient displayed in the Care Documentation where the patient's medication information existed, causing staff confusion | |
| IR19 | Partial output | Software not accessible | A software conversion programme was not accessible to handle a vaccination file completely without valid vaccination registration attributing to delays in patient care | |
| IR20 | Partial output | Interface with other software systems or components | When a prescriber changes a prescription with a ‘prescription type without time’ to ‘prescription type with time’ via Dosage Overview, the administered dose is no longer visible in the administered list but in the administered dialogue exposing the patients to the risks of serious deterioration of health | |
| IR21 | No output | Network/server down or slow | A network down of the electronic prescribing system led to the medicine list not working for a longer period | |
| IR22 | No output | Software functionality | The ‘exit’ function of the medicine list was not functioning after making the latest change in the system, which affected healthcare quality | |
| IR23 | Did not enter or retrieve | No output | The sample responses from the last sampling were not sent, and the user did not receive information in the pharmaceutical module, placing the patients at risk to care delivery | |
| IR24 | System configuration | The system was not configured to give a warning for registered hypersensitivity information about medicine causing risks of serious deterioration of patients’ health |
IR: incident report; EMR: electronic medical records; IT: information technology.