Published April 6, 2021
Imagine a nurse was supposed to enter a new prescription into a patient’s digital chart, but failed to change the default dosage. Later, the patient was administered too much medication. How could that happen, and how can the hospital prevent it from occurring again?
According to a new School of Management study, if you ask a doctor or an information technology (IT) expert, you’re likely to get two different answers for why technology-related medical errors occur — and, critically, what can be done to fix them.
“Health care experts are more likely to attribute errors to the implementation and use of an IT tool,” says Pavankumar Mulgund, clinical assistant professor of management science and systems. “By contrast, IT experts tend to identify software design and functionality as the cause of tech-related errors.”
The study was published by JMIR Human Factors and promoted on the website of the Agency for Healthcare Research and Quality, part of the U.S. Department of Health and Human Services.
To start, the researchers reviewed more than 300 published articles and extracted 67 errors in hospitals when the use of IT compromised a patient’s safety. From there, they interviewed experienced medical and IT experts, who categorized the errors based on their opinion of what caused them and recommended ways to avoid them in the future.
When errors were related to information security, compliance and privacy, both sets of experts shared similar perceptions. Beyond that, however, their perspectives diverged. IT professionals usually identified technical issues — software, hardware or user interface problems — as potential causes, while doctors and nurses often pointed to workflows, processes or clinical staff as the source of the error.
“Employees prioritize different goals and have different backgrounds and training,” says Raj Sharman, professor of management science and systems. “Our research shows that patient safety errors can occur when IT and medical teams do not understand each other’s perspectives and processes well enough.”
According to the study, development of clinical applications typically includes input from clinicians themselves — but the researchers recommend going further to ensure that IT experts understand how workloads, processes and other variables impact how the software will be used.
“We suggest software companies immerse their developers in clinical environments for a short period, so that environment is built into their psyche,” Mulgund says. “With more extensive training and exposure to end users and situations, development teams will design better software and develop more effective implementation strategies.”
Theophile Ndabu, a School of Management doctoral student, led the study, with co-authors Mulgund, Sharman and Ranjit Singh, an adjunct faculty member in management science and systems and an associate professor of family medicine in the Jacobs School of Medicine and Biomedical Sciences at UB.