Points of Failure: A Systematic Review of information-flow using Medication Use Cases

Background: Medication errors pose a significant problem in the clinical environment, causing adverse events which impact patient safety. Problem: The introduction of electronic information and clinical systems have reduced medication errors but have also been identified as creating new types of errors. Method: Using the previously developed Hermon model, this research aimed to identify and understand medication errors due to clinical information-flow in the Australian General Practice (primary care) setting. The research used existing general practice medication error report cases from the Threat to Patient Safety (TAPS) Study to map against the Hermon model, and validated this mapping through consultations with general practitioners. Findings: The findings informed the refinement of the Hermon Model, and assisted in identifying medication errors points of information-flow failure in general practice information-flow. Impact: This study has significance to improve patient safety and inform the development of general practice desktop systems through identification and understanding of information-flow points of failure which result in medication errors.