OBJECTIVE: To conduct a meta-ethnographic synthesis summarizing the overarching themes of the qualitative literature on nurse interaction with medication administration technologies (MAT) comprising electronic medication administration record (eMAR) and bar-coded medication administration (BCMA). MATERIALS AND METHODS: We searched scientific databases from their inception until September 23, 2024, resulting in 2270 unique articles, and extracted data from 27 articles. Scientific rigor was assessed by the Standards for Reporting Qualitative Research (SRQR) checklist. Noblit and Hare's methodology was used to conduct a meta-ethnography to identify and interpret emergent themes. RESULTS: SRQR revealed low-to-medium methodological quality and theoretical framing of the literature. We found 6 overarching themes connecting MAT with nursing work: (1) View of the MAT system as mechanistic and invariant vs living and co-evolving with its users drives the research approach; (2) MAT limits nurse autonomy; (3) MAT unnaturally splits the medication administration workflow; (4) Nurses must manage MAT challenges at the sharp end; (5) MAT does not align with social dependencies of nursing work; and (6) MAT increases perceived safety but can also result in new types of errors. DISCUSSION: MAT does not support key cognitive work that nurses must perform to maintain safety. Additionally, MAT can impede problem solving during medication management and limit nursing autonomy that is essential for safe medication administration. CONCLUSION: Recommendations based in human factors engineering recognizing how MAT design impacts nursing work and workload are essential in improving the fit of MAT to nurse cognitive workflows.

OBJECTIVES: (1) Characterize persistent hazards and inefficiencies in inpatient medication administration; (2) Explore cognitive attributes of medication administration tasks; and (3) Discuss strategies to reduce medication administration technology-related hazards. MATERIALS AND METHODS: Interviews were conducted with 32 nurses practicing at 2 urban, eastern and western US health systems. Qualitative analysis using inductive and deductive coding included consensus discussion, iterative review, and coding structure revision. We abstracted hazards and inefficiencies through the lens of risks to patient safety and the cognitive perception-action cycle (PAC). RESULTS: Persistent safety hazards and inefficiencies related to MAT organized around the PAC cycle included: (1) Compatibility constraints create information silos; (2) Missing action cues; (3) Intermittent communication flow between safety monitoring systems and nurses; (4) Occlusion of important alerts by other, less helpful alerts; (5) Dispersed information: Information required for tasks is not collocated; (6) Inconsistent data organization: Mismatch of the display and the user's mental model; (7) Hidden medication administration technologies (MAT) limitations: Inaccurate beliefs about MAT functionality contribute to overreliance on the technology; (8) Software rigidity causes workarounds; (9) Cumbersome dependencies between technology and the physical environment; and (10) Technology breakdowns require adaptive actions. DISCUSSION: Errors might persist in medication administration despite successful Bar Code Medication Administration and Electronic Medication Administration Record deployment for reducing errors. Opportunities to improve MAT require a deeper understanding of high-level reasoning in medication administration, including control over the information space, collaboration tools, and decision support. CONCLUSION: Future medication administration technology should consider a deeper understanding of nursing knowledge work for medication administration.

Despite basic federal requirements promoting a user-centered design approach to electronic health record (EHR) development and usability testing there have been usability and safety risks with EHR technology. Four EHR vendors were asked to provide written descriptions of their usability practices, and we reviewed these descriptions to identify areas where there has been advancement and areas for improvement. All 4 vendors described user-centered design processes and usability testing methods that demonstrate advancement from previous studies of vendor practices. Importantly, vendors are also beginning to address aspects of EHR implementation that play a critical role in shaping EHR usability. There are important areas for improvement in vendor practices including a greater focus on safety and on measurement and benchmarking. Vendors sharing their current usability practices demonstrates a step toward greater transparency which has typically been lacking.

OBJECTIVE: We sought to determine rates of computerized provider order entry (CPOE) patient identity verification and when and where in the ordering process verification occurred. MATERIALS AND METHODS: Fifty-five physicians from 4 healthcare systems completed simulated patient scenarios using their respective CPOE system (Epic or Cerner). Eye movements were recorded and analyzed. RESULTS: Across all participants patient id was verified significantly more often than not (62.4% vs 37.6%). Vendor A had significantly higher verification rates than not; vendor B had no difference. Participants using vendor A verified information significantly more often before signing the order than after (88.4% vs 11.6%); there was no difference in vendor B. The banner bar was the most frequent verification location. DISCUSSION: Factors such as CPOE design, physician training, and the use of a simulated methodology may be impacting verification rates. CONCLUSIONS: Verification rates vary by CPOE product, and this can have patient safety consequences.

Wrong-patient errors from inadvertent menu selections while using computerized provider order entry (CPOE) systems could have fatal consequences. This study investigated whether the manipulation of CPOE interface design could improve healthcare providers’ ability to recognize patient selection errors and also decrease the time to error recognition. Using a 2 × 2 design, 120 participants were randomly assigned to one of four groups, interacting with different versions of a simulated CPOE: (1) control – standard version; (2) highlighted selection – the selected patient row was highlighted for 2 s, by blanking the rest of the screen; (3) photo – photographs of patients’ faces were displayed in all screens; (4) combined – with photo and highlighted selection. Each participant navigated through five order scenarios. On the last scenario, an error was simulated by directing the participant to a wrong patient. Recognition rates of the wrong-patient error and times to error recognition were significantly improved for the highlighted selection, photo, and combined groups, relative to the control group. These results suggest that the addition of patient photos and highlighted selection could substantially reduce errors in CPOE systems and other applications.

To characterize the variability in usability and safety of EHRs from two vendors across four healthcare systems (2 Epic and 2 Cerner). Twelve to 15 emergency medicine physicians participated from each site and completed six clinical scenarios. Keystroke, mouse click, and video data were collected. From the six scenarios, two diagnostic imaging, laboratory, and medication tasks were analyzed. There was wide variability in task completion time, clicks, and error rates. For certain tasks, there were an average of a nine-fold difference in time and eight-fold difference in clicks. Error rates varied by task (X-ray 16.7% to 25%, MRI: 0 to 10%, Lactate: 0% to 14.3%, Tylenol: 0 to 30%; Taper: 16.7% to 50%). The variability in time, clicks, and error rates highlights the need for improved implementation optimization. EHR implementation, in addition to vendor design and development, is critical to usable and safe products.

Interruptions in the emergency department (ED) can have serious patient safety consequences, and few solutions exist to mitigate the disruptiveness of interruptions. We developed a theoretically motivated model to predict the likelihood of emergency physicians returning to an interrupted task. Eighteen emergency physicians were observed individually for two-hour blocks of time, resulting in a total of 2160 minutes of observation and 231 interruptions. We used a mixed effects logistic regression model to predict the likelihood of primary task resumption after interruptions. The likelihood of primary task resumption was predicted by memory decay, measured by the duration of the interruption, workload, measured by the patient volume during the shift, and whether shift was day or night. With a better understanding of these interruptions, we can help design interventions to manage interruptions, minimize medical errors, and improve patient safety.

Despite the widespread adoption of electronic health records (EHRs), usability of many EHRs continues to be suboptimal, with some vendors failing to meet usability standards, resulting in clinician frustration and patient safety hazards. In an effort to increase EHR vendor competition on usability, recommendations have been made and legislation drafted to develop comparison tools that would allow purchasers to better understand the usability of EHR products prior to purchase. Usability comparison can be based on EHR vendor design and development processes, vendor usability testing as part of the Office of the National Coordinator for Health Information Technology certification program, and usability of implemented products. Barriers exist within the current certified health technology program that prevent effective comparison of usability during each of these stages. We describe the importance of providing purchasers with improved information about EHR usability, barriers to making usability comparisons, and solutions to overcome these barriers.

OBJECTIVE: Currently, there are few resources for electronic health record (EHR) purchasers and end users to understand the usability processes employed by EHR vendors during product design and development. We developed a framework, based on human factors literature and industry standards, to systematically evaluate the user-centered design processes and usability testing methods used by EHR vendors. MATERIALS AND METHODS: We reviewed current usability certification requirements and the human factors literature to develop a 15-point framework for evaluating EHR products. The framework is based on 3 dimensions: user-centered design process, summative testing methodology, and summative testing results. Two vendor usability reports were retrieved from the Office of the National Coordinator's Certified Health IT Product List and were evaluated using the framework. RESULTS: One vendor scored low on the framework (5 pts) while the other vendor scored high on the framework (15 pts). The 2 scored vendor reports demonstrate the framework's ability to discriminate between the variabilities in vendor processes and to determine which vendors are meeting best practices. DISCUSSION: The framework provides a method to more easily comprehend EHR vendors' usability processes and serves to highlight where EHR vendors may be falling short in terms of best practices. The framework provides a greater level of transparency for both purchasers and end users of EHRs. CONCLUSION: The framework highlights the need for clearer certification requirements and suggests that the authorized certification bodies that examine vendor usability reports may need to be provided with clearer guidance.

IMPORTANCE AND OBJECTIVES: As health information technologies become more prevalent in physician workflow, it is increasingly important to understand how physicians are using and interacting with these systems. This includes understanding how physicians search for information presented through health information technology systems. Eye tracking technologies provide a useful technique to understand how physicians visually search for information. However, analyzing eye tracking data can be challenging and is often done by measuring summative metrics, such as total time looking at a specific area and first-order transitions. METHODS: In this paper, we propose an algorithmic approach to identify different visual search patterns. We demonstrate this approach by identifying common visual search patterns from physicians using a simulated prototype emergency department patient tracking system. RESULTS AND CONCLUSIONS: We evaluate and compare the visual search pattern results to first-order transition results. We discuss the benefits and limitations of this approach and insights from this initial evaluation.

OBJECTIVE: The primary objective was to evaluate time, number of interface actions, and accuracy on medication reconciliation tasks using a novel user interface (Twinlist, which lays out the medications in five columns based on similarity and uses animation to introduce the grouping - www.cs.umd.edu/hcil/sharp/twinlist) compared to a Control interface (where medications are presented side by side in two columns). A secondary objective was to assess participant agreement with statements regarding clarity and utility and to elicit comparisons. MATERIAL AND METHODS: A 1 × 2 within-subjects experimental design was used with interface (Twinlist or Control) as an independent variable; time, number of clicks, scrolls, and errors were used as dependent variables. Participants were practicing medical providers with experience performing medication reconciliation but no experience with Twinlist. They reconciled two cases in each interface (in a counterbalanced order), then provided feedback on the design of the interface. RESULTS: Twenty medical providers participated in the study for a total of 80 trials. The trials using Twinlist were statistically significantly faster (18%), with fewer clicks (40%) and scrolls (60%). Serious errors were noted 12 and 31 times in Twinlist and Control trials, respectively. DISCUSSION: Trials using Twinlist were faster and more accurate. Subjectively, participants rated Twinlist more favorably than Control. They valued the novel layout of the drugs, but indicated that the included animation would be valuable for novices, but not necessarily for advanced users. Additional feedback from participants provides guidance for further development and clinical implementations. CONCLUSIONS: Cognitive support of medication reconciliation through interface design can significantly improve performance and safety.

The usability of electronic health records (EHRs) continues to be a point of dissatisfaction for providers, despite certification requirements from the Office of the National Coordinator that require EHR vendors to employ a user-centered design (UCD) process. To better understand factors that contribute to poor usability, a research team visited 11 different EHR vendors in order to analyze their UCD processes and discover the specific challenges that vendors faced as they sought to integrate UCD with their EHR development. Our analysis demonstrates a diverse range of vendors' UCD practices that fall into 3 categories: well-developed UCD, basic UCD, and misconceptions of UCD. Specific challenges to practicing UCD include conducting contextually rich studies of clinical workflow, recruiting participants for usability studies, and having support from leadership within the vendor organization. The results of the study provide novel insights for how to improve usability practices of EHR vendors.