Medication safety incidents in paediatric oncology after electronic medication management system implementation

Eur J Cancer Care (Engl). 2019 Nov;28(6):e13152. doi: 10.1111/ecc.13152. Epub 2019 Aug 22.


Objective: To explore medication safety issues related to use of an electronic medication management system (EMM) in paediatric oncology practice, through the analysis of patient safety incident reports.

Methods: We analysed 827 voluntarily reported incidents relating to oncology patients that occurred over an 18-month period immediately following implementation of an EMM in a paediatric hospital in Australia. We identified medication-related and EMM-related incidents and carried out a content analysis to identify patterns.

Results: We found ~79% (n = 651) of incidents were medication-related and, of these, ~45% (n = 294) were EMM-related. Medication-related incidents included issues with: prescribing; dispensing; administration; patient transfers; missing chemotherapy protocols and information on current stage of patient treatment; coordination of chemotherapy administration; handling or storing medications; children or families handling medications. EMM-related incidents were classified into four groups: technical issues, issues with the user experience, unanticipated problems in EMM workflow, and missing safety features.

Conclusions: Incidents reflected difficulties with managing therapies rich in interdependencies. EMM, and especially its 'automaticity', contributed to these incidents. As EMM impacts on safety in such high-risk settings, it is essential that users are aware of and attend to EMM automatic behaviours and are equipped to troubleshoot them.

Keywords: computerized provider order entry system; evaluation research; hospital oncology services; medication errors; paediatrics; patient safety.

MeSH terms

  • Adolescent
  • Australia
  • Child
  • Child, Preschool
  • Electronic Prescribing
  • Hospitals, Pediatric
  • Humans
  • Infant
  • Infant, Newborn
  • Medication Errors*
  • Medication Systems, Hospital*
  • Neoplasms / drug therapy*
  • Patient Safety*
  • Pediatrics*
  • Risk Management
  • Tertiary Care Centers
  • Young Adult