Need medicine in hospital? Our study finds how often IT flaws lead to the wrong drug or dose
Why Read This
What Makes This Article Worth Your Time
Summary
What This Article Is About
Johanna Westbrook’s research reveals that one in three medication errors in hospitals are caused by flaws in electronic medical systems rather than human error. Her team analyzed over 35,000 medication orders at a major metropolitan hospital, examining errors made when medications are prescribed via computer-based systems. The study tracked technology-related errors at three critical time points: the first 12 weeks of system implementation, one year later, and four years after deployment.
Contrary to expectations, the research found that technology-related errors persisted at the same rate four years after implementation as they did in the first year, suggesting that poor system design rather than user inexperience drives these errors. High-risk medications like oxycodone, fentanyl, and insulin were frequently associated with technology-related errors, and examples included overwhelming drop-down menus with excessive dose options and automated dispensing cabinets with inadequate search safeguards. Westbrook emphasizes that without continuous monitoring and system improvements, hospitals cannot fully benefit from digital health technologies.
Key Points
Main Takeaways
One-Third Are Technology Errors
Research analyzing 35,000+ medication orders found that 33% of medication errors stem from electronic system design flaws, not clinician mistakes.
Errors Persist Over Time
Technology-related error rates remained unchanged four years after system implementation, indicating design problems rather than a temporary learning curve.
High-Risk Medications Affected
Oxycodone, fentanyl, and insulin—medications with serious adverse effects if dosed incorrectly—were frequently involved in technology-related errors.
Poor Interface Design
Overwhelming drop-down menus with excessive medication options and inadequate search filters in automated dispensing cabinets create dangerous selection errors.
System-Wide Vulnerability
Technology-related errors can occur at any point in patient care, from prescription entry to medication dispensing and administration.
Continuous Monitoring Needed
Without ongoing system evaluation, updates, and clinician feedback mechanisms, hospitals cannot realize the full safety potential of digital health technologies.
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Article Analysis
Breaking Down the Elements
Main Idea
Technology Design, Not Users, Drives Medical Errors
The central thesis is that a significant proportion of medication errors in hospitals—one in three—are caused by flawed electronic system design rather than clinician mistakes. This matters because it shifts accountability from individual healthcare workers to system developers and administrators, and demonstrates that even years after implementation, poorly designed medical technology continues to endanger patient safety without continuous monitoring and improvement.
Purpose
Advocate for System-Level Safety Reform
Westbrook writes to inform healthcare stakeholders about technology-related medication errors while advocating for systematic improvements in health IT design, continuous monitoring protocols, and clinician feedback mechanisms. The article serves as both an evidence-based warning about current digital health vulnerabilities and a call to action for institutional commitment to ongoing system optimization rather than one-time implementation.
Structure
Problem Introduction → Research Evidence → Case Examples → Solutions
The article opens by contextualizing electronic prescribing systems before presenting research findings (one-third error rate, persistence over time). It then moves to concrete examples of how errors occur (drop-down menus, automated dispensing cabinets, specific cases like the South Australia pregnancy miscalculation), and concludes with recommended solutions including continuous monitoring, improved developer understanding, and systematic clinician feedback mechanisms.
Tone
Authoritative, Concerned & Evidence-Based
Westbrook maintains an authoritative academic tone grounded in research data while expressing clear concern about patient safety. The writing is accessible to non-specialist audiences yet preserves scientific credibility through specific statistics and documented examples. The tone balances urgency about the problem with measured, constructive recommendations rather than alarmism.
Key Terms
Vocabulary from the Article
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Tough Words
Challenging Vocabulary
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The quality of being suitable, fitting, or proper for a particular purpose, person, or situation.
“Every time you are prescribed medicine in hospital a computer will prompt your doctor about the appropriateness of the medicine and its dose.”
Healthcare professionals, typically doctors or nurse practitioners, authorized to write orders for medications or treatments for patients.
“Prescribers can be confronted with a long list of possible dose options for a medication and accidentally choose the wrong one.”
The act of distributing or providing medications or medical supplies in measured amounts according to a prescription.
“She obtained the medicine from a computer-controlled dispensing cabinet (known as an automated dispensing cabinet), which is used to store, dispense and track medicines.”
A sudden loss of heart function where the heart stops beating effectively, preventing blood circulation throughout the body.
“The nurse selected and administered the wrong drug to the patient, causing cardiac arrest and the nurse faced a criminal trial.”
Medical procedures to artificially initiate or accelerate labor in pregnant women before natural onset.
“This miscalculated the due date for more than 1,700 pregnant women, possibly prompting premature inductions of labour.”
To make a system, design, or process as effective, functional, or beneficial as possible by improving its performance.
“For each example, we include recommendations to optimise the systems.”
Reading Comprehension
Test Your Understanding
5 questions covering different RC question types
1According to the research, technology-related medication errors decrease significantly as healthcare professionals become more familiar with electronic systems over time.
2What proportion of medication errors in the hospital studied were found to be technology-related?
3Select the sentence that best explains why technology-related medication errors are particularly concerning.
4Based on the article, determine whether each statement about technology-related medication errors is True or False.
The research team reviewed more than 35,000 medication orders to understand error frequency.
Automated dispensing cabinets are being phased out in Australian hospitals due to safety concerns.
The article describes a case where a nurse administered the wrong medication obtained from a poorly designed automated dispensing cabinet.
Select True or False for all three statements, then click “Check Answers”
5Based on the article’s discussion of technology-related medication errors, what can be inferred about the author’s perspective on digital health systems?
FAQ
Frequently Asked Questions
Technology-related medication errors are mistakes in prescribing, dispensing, or administering medications that are facilitated by the design or functionality of electronic health systems rather than caused by clinician mistakes. Examples include selecting the wrong medication from confusing drop-down menus with excessive options, errors enabled by poorly designed automated dispensing cabinets, or incorrect doses calculated by flawed built-in calculators. These errors stem from programming flaws, suboptimal interface design, or inadequate system safeguards.
The research found that technology-related error rates remained constant four years after implementation because these errors are caused by fundamental system design flaws rather than user inexperience. While there is an initial learning curve during the first weeks of use, structural problems like overwhelming medication option lists, inadequate search filters, or poorly designed interfaces continue to create error opportunities regardless of staff familiarity. This persistence demonstrates that system improvement, not just user training, is essential for reducing these errors.
Safety bulletins are documents produced by Westbrook’s research team that describe specific examples of poor health system design identified through research or reported by healthcare workers. Each bulletin includes detailed descriptions of the design flaw (such as drop-down menus allowing dangerous medication routes or calculators that miscalculate pediatric doses) along with specific recommendations for system optimization. Healthcare organizations can use these bulletins to test their own systems for similar vulnerabilities and implement corrective measures before errors occur.
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This article is rated Intermediate level because it requires understanding of healthcare systems terminology, statistical interpretation, and the ability to synthesize evidence-based arguments about technology and patient safety. While the language is accessible to general readers, the content assumes familiarity with medical contexts and presents research findings that require critical analysis. Intermediate readers can follow the logical progression from problem identification through evidence presentation to proposed solutions.
This research is critical because it demonstrates that a substantial portion of medication errors—one in three—result from preventable system design flaws rather than human mistakes. By identifying technology as a key contributor to errors involving high-risk medications like oxycodone and insulin, the research shifts focus from blaming individual clinicians to demanding systemic improvements. With increasing digitization of healthcare and the introduction of AI systems, understanding and addressing technology-related errors now is essential to prevent future patient harm and realize the safety benefits that well-designed digital systems can provide.
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