{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,2,1]],"date-time":"2026-02-01T00:39:32Z","timestamp":1769906372643,"version":"3.49.0"},"reference-count":53,"publisher":"Oxford University Press (OUP)","issue":"1","license":[{"start":{"date-parts":[[2020,11,22]],"date-time":"2020-11-22T00:00:00Z","timestamp":1606003200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/academic.oup.com\/journals\/pages\/open_access\/funder_policies\/chorus\/standard_publication_model"}],"funder":[{"DOI":"10.13039\/100000133","name":"Agency for Healthcare Research and Quality","doi-asserted-by":"publisher","award":["R21HS025443"],"award-info":[{"award-number":["R21HS025443"]}],"id":[{"id":"10.13039\/100000133","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2021,1,15]]},"abstract":"<jats:title>Abstract<\/jats:title>\n               <jats:sec>\n                  <jats:title>Objective<\/jats:title>\n                  <jats:p>We utilized a computerized order entry system\u2013integrated function referred to as \u201cvoid\u201d to identify erroneous orders (ie, a \u201cvoid\u201d order). Using voided orders, we aimed to (1) identify the nature and characteristics of medication ordering errors, (2) investigate the risk factors associated with medication ordering errors, and (3) explore potential strategies to mitigate these risk factors.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Materials and Methods<\/jats:title>\n                  <jats:p>We collected data on voided orders using clinician interviews and surveys within 24 hours of the voided order and using chart reviews. Interviews were informed by the human factors\u2013based SEIPS (Systems Engineering Initiative for Patient Safety) model to characterize the work systems\u2013based risk factors contributing to ordering errors; chart reviews were used to establish whether a voided order was a true medication ordering error and ascertain its impact on patient safety.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Results<\/jats:title>\n                  <jats:p>During the 16-month study period (August 25, 2017, to December 31, 2018), 1074 medication orders were voided; 842 voided orders were true medication errors (positive predictive value\u2009=\u200978.3\u2009\u00b1\u20091.2%). A total of 22% (n\u2009=\u2009190) of the medication ordering errors reached the patient, with at least a single administration, without causing patient harm. Interviews were conducted on 355 voided orders (33% response). Errors were not uniquely associated with a single risk factor, but the causal contributors of medication ordering errors were multifactorial, arising from a combination of technological-, cognitive-, environmental-, social-, and organizational-level factors.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Conclusions<\/jats:title>\n                  <jats:p>The void function offers a practical, standardized method to create a rich database of medication ordering errors. We highlight implications for utilizing the void function for future research, practice and learning opportunities.<\/jats:p>\n               <\/jats:sec>","DOI":"10.1093\/jamia\/ocaa264","type":"journal-article","created":{"date-parts":[[2020,10,6]],"date-time":"2020-10-06T19:15:36Z","timestamp":1602011736000},"page":"86-94","source":"Crossref","is-referenced-by-count":13,"title":["Risk factors associated with medication ordering errors"],"prefix":"10.1093","volume":"28","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-0235-1632","authenticated-orcid":false,"given":"Joanna","family":"Abraham","sequence":"first","affiliation":[{"name":"Department of Anesthesiology, Washington University School of Medicine in St. Louis,St. Louis, Missouri, USA"},{"name":"Institute for Informatics, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA"}]},{"given":"William L","family":"Galanter","sequence":"additional","affiliation":[{"name":"Department of Medicine, College of Medicine, University of Illinois at Chicago,Chicago, Illinois, USA"},{"name":"Department of Pharmacy Systems, Outcome and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois, USA"}]},{"given":"Daniel","family":"Touchette","sequence":"additional","affiliation":[{"name":"Department of Pharmacy Systems, Outcome and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois, USA"}]},{"given":"Yinglin","family":"Xia","sequence":"additional","affiliation":[{"name":"Department of Medicine, College of Medicine, University of Illinois at Chicago,Chicago, Illinois, USA"}]},{"given":"Katherine J","family":"Holzer","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology, Washington University School of Medicine in St. Louis,St. Louis, Missouri, USA"}]},{"given":"Vania","family":"Leung","sequence":"additional","affiliation":[{"name":"Department of Medicine, College of Medicine, University of Illinois at Chicago,Chicago, Illinois, USA"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4119-4836","authenticated-orcid":false,"given":"Thomas","family":"Kannampallil","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology, Washington University School of Medicine in St. Louis,St. Louis, Missouri, USA"},{"name":"Institute for Informatics, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA"}]}],"member":"286","published-online":{"date-parts":[[2020,11,22]]},"reference":[{"key":"2021011515545499300_ocaa264-B1"},{"issue":"9","key":"2021011515545499300_ocaa264-B2","doi-asserted-by":"crossref","first-page":"765","DOI":"10.1136\/bmjqs-2013-002572","article-title":"Identifying systems failures in the pathway to a catastrophic event: an analysis of national incident report data relating to vinca alkaloids","volume":"23","author":"Franklin","year":"2014","journal-title":"BMJ Qual Saf"},{"key":"2021011515545499300_ocaa264-B3","first-page":"796","article-title":"Effect of a computerized provider order entry (CPOE) system on medication orders at a community hospital and university hospital","volume-title":"AMIA Ann Symp Proc","author":"Wess","year":"2007"},{"issue":"10","key":"2021011515545499300_ocaa264-B4","doi-asserted-by":"crossref","first-page":"1197","DOI":"10.1001\/jama.293.10.1197","article-title":"Role of computerized physician order entry systems in facilitating medication errors","volume":"293","author":"Koppel","year":"2005","journal-title":"JAMA"},{"issue":"6","key":"2021011515545499300_ocaa264-B5","doi-asserted-by":"crossref","first-page":"774","DOI":"10.1136\/amiajnl-2011-000255","article-title":"Factors contributing to an increase in duplicate medication order errors after CPOE implementation","volume":"18","author":"Wetterneck","year":"2011","journal-title":"J Am Med Inform Assoc"},{"issue":"7","key":"2021011515545499300_ocaa264-B6","doi-asserted-by":"crossref","first-page":"768","DOI":"10.1177\/0091270003254794","article-title":"Reducing medication errors and increasing patient safety: case studies in clinical pharmacology","volume":"43","author":"Benjamin","year":"2003","journal-title":"J Clin Pharmacol"},{"issue":"1","key":"2021011515545499300_ocaa264-B7","doi-asserted-by":"crossref","first-page":"39","DOI":"10.1016\/j.profnurs.2005.12.008","article-title":"Characteristics of medication errors made by students during the administration phase: a descriptive study","volume":"22","author":"Wolf","year":"2006","journal-title":"J Prof Nurs"},{"issue":"1","key":"2021011515545499300_ocaa264-B8","doi-asserted-by":"crossref","first-page":"29","DOI":"10.1001\/jama.1995.03530010043033","article-title":"Incidence of adverse drug events and potential adverse drug events: Implications for prevention","volume":"274","author":"Bates","year":"1995","journal-title":"JAMA"},{"issue":"6","key":"2021011515545499300_ocaa264-B9","doi-asserted-by":"crossref","first-page":"651","DOI":"10.1111\/j.1365-2125.2009.03422.x","article-title":"Prevention of medication errors: detection and audit","volume":"67","author":"Montesi","year":"2009","journal-title":"Br J Clin Pharmacol"},{"issue":"23","key":"2021011515545499300_ocaa264-B10","doi-asserted-by":"crossref","first-page":"2427","DOI":"10.1001\/jama.2011.813","article-title":"Paid malpractice claims for adverse events in inpatient and outpatient settings","volume":"305","author":"Bishop","year":"2011","journal-title":"JAMA"},{"issue":"11","key":"2021011515545499300_ocaa264-B11","doi-asserted-by":"crossref","first-page":"992","DOI":"10.1002\/pds.1811","article-title":"Methodological variability in detecting prescribing errors and consequences for the evaluation of interventions","volume":"18","author":"Franklin","year":"2009","journal-title":"Pharmacoepidemiol Drug Saf"},{"key":"2021011515545499300_ocaa264-B12","doi-asserted-by":"crossref","DOI":"10.2307\/j.ctt7srgf","volume-title":"Normal Accidents: Living with High Risk Technologies","author":"Perrow","year":"2011"},{"issue":"4","key":"2021011515545499300_ocaa264-B13","doi-asserted-by":"crossref","first-page":"264","DOI":"10.1136\/bmjqs-2014-003555","article-title":"Computerised physician order entry-related medication errors: analysis of reported errors and vulnerability testing of current systems","volume":"24","author":"Schiff","year":"2015","journal-title":"BMJ Qual Saf"},{"issue":"6","key":"2021011515545499300_ocaa264-B14","doi-asserted-by":"crossref","first-page":"370","DOI":"10.1056\/NEJM199102073240604","article-title":"Incidence of adverse events and negligence in hospitalized patients","volume":"324","author":"Brennan","year":"1991","journal-title":"N Engl J Med"},{"issue":"26","key":"2021011515545499300_ocaa264-B15","doi-asserted-by":"crossref","first-page":"1963","DOI":"10.1056\/NEJM199612263352606","article-title":"Relation between negligent adverse events and the outcomes of medical-malpractice litigation","volume":"335","author":"Brennan","year":"1996","journal-title":"N Engl J Med"},{"issue":"4","key":"2021011515545499300_ocaa264-B16","doi-asserted-by":"crossref","first-page":"245","DOI":"10.1056\/NEJM199107253250405","article-title":"Relation between malpractice claims and adverse events due to negligence: results of the Harvard Medical Practice Study III","volume":"325","author":"Localio","year":"1991","journal-title":"N Engl J Med"},{"key":"2021011515545499300_ocaa264-B17","first-page":"1623","article-title":"Clinician perspectives on duplicate medication ordering errors","volume":"2018","author":"Abraham","journal-title":"AMIA Annu Symp Proc"},{"issue":"4","key":"2021011515545499300_ocaa264-B18","doi-asserted-by":"crossref","first-page":"299","DOI":"10.1136\/bmjqs-2017-006606","article-title":"Reasons for computerised provider order entry (CPOE)-based inpatient medication ordering errors: an observational study of voided orders","volume":"27","author":"Abraham","year":"2018","journal-title":"BMJ Qual Saf"},{"issue":"4","key":"2021011515545499300_ocaa264-B19","doi-asserted-by":"crossref","first-page":"762","DOI":"10.1093\/jamia\/ocw187","article-title":"Learning from errors: analysis of medication order voiding in CPOE systems","volume":"24","author":"Kannampallil","year":"2017","journal-title":"J Am Med Inform Assoc"},{"key":"2021011515545499300_ocaa264-B20"},{"issue":"2","key":"2021011515545499300_ocaa264-B21","doi-asserted-by":"crossref","first-page":"316","DOI":"10.1093\/jamia\/ocw125","article-title":"Computerized prescriber order entry\u2013related patient safety reports: analysis of 2522 medication errors","volume":"24","author":"Amato","year":"2017","journal-title":"J Am Med Inform Assoc"},{"issue":"6 suppl","key":"2021011515545499300_ocaa264-B22","doi-asserted-by":"crossref","first-page":"S90","DOI":"10.1097\/CCM.0b013e3181dd8de2","article-title":"The value of human factors to medication and patient safety in the ICU","volume":"38","author":"Scanlon","year":"2010","journal-title":"Crit Care Med"},{"issue":"4","key":"2021011515545499300_ocaa264-B23","doi-asserted-by":"crossref","first-page":"389","DOI":"10.4037\/NCI.0b013e3182a8b516","article-title":"Medication errors in the intensive care unit: literature review using the SEIPS model","volume":"24","author":"Frith","year":"2013","journal-title":"AACN Adv Crit Care"},{"issue":"suppl 1","key":"2021011515545499300_ocaa264-B24","doi-asserted-by":"crossref","first-page":"i50","DOI":"10.1136\/qshc.2005.015842","article-title":"Work system design for patient safety: the SEIPS model","volume":"15","author":"Carayon","year":"2006","journal-title":"Qual Saf Health Care"},{"issue":"1","key":"2021011515545499300_ocaa264-B25","doi-asserted-by":"crossref","first-page":"4","DOI":"10.1177\/1557234X13492976","article-title":"Macroergonomics in health care quality and patient safety","volume":"8","author":"Carayon","year":"2013","journal-title":"Rev Hum Factors Ergon"},{"key":"2021011515545499300_ocaa264-B26","year":"2001"},{"issue":"6","key":"2021011515545499300_ocaa264-B27","doi-asserted-by":"crossref","first-page":"461","DOI":"10.1016\/0260-6917(91)90009-Y","article-title":"A method of analysing interview transcripts in qualitative research","volume":"11","author":"Burnard","year":"1991","journal-title":"Nurse Educ Today"},{"issue":"2","key":"2021011515545499300_ocaa264-B28","doi-asserted-by":"crossref","first-page":"77","DOI":"10.1191\/1478088706qp063oa","article-title":"Using thematic analysis in psychology","volume":"3","author":"Braun","year":"2006","journal-title":"Qual Res Psychol"},{"issue":"2","key":"2021011515545499300_ocaa264-B29","doi-asserted-by":"crossref","first-page":"432","DOI":"10.1093\/jamia\/ocw119","article-title":"A systematic review of the types and causes of prescribing errors generated from using computerized provider order entry systems in primary and secondary care","volume":"24","author":"Brown","year":"2017","journal-title":"J Am Med Inform Assoc"},{"issue":"5","key":"2021011515545499300_ocaa264-B30","doi-asserted-by":"crossref","first-page":"361","DOI":"10.1136\/bmjqs-2011-000299","article-title":"Identifying, understanding and overcoming barriers to medication error reporting in hospitals: a focus group study","volume":"21","author":"Hartnell","year":"2012","journal-title":"BMJ Qual Saf"},{"issue":"10","key":"2021011515545499300_ocaa264-B31","doi-asserted-by":"crossref","first-page":"690","DOI":"10.1016\/j.ijmedinf.2010.08.001","article-title":"Effect of predefined order sets and usability problems on efficiency of computerized medication ordering","volume":"79","author":"Khajouei","year":"2010","journal-title":"Int J Med Inform"},{"issue":"3","key":"2021011515545499300_ocaa264-B32","doi-asserted-by":"crossref","first-page":"77","DOI":"10.1097\/00002727-200111000-00007","article-title":"Managing medication errors by design","volume":"24","author":"Brown","year":"2001","journal-title":"Crit Care Nurs Q"},{"issue":"10","key":"2021011515545499300_ocaa264-B33","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1136\/bmjqs-2019-010436","article-title":"Effects of CPOE-based medication ordering on outcomes: an overview of systematic reviews","volume":"29","author":"Abraham","year":"2020","journal-title":"BMJ Qual Saf"},{"issue":"1","key":"2021011515545499300_ocaa264-B34","doi-asserted-by":"crossref","first-page":"e211","DOI":"10.1542\/peds.2011-2984","article-title":"The use of patient pictures and verification screens to reduce computerized provider order entry errors","volume":"130","author":"Hyman","year":"2012","journal-title":"Pediatrics"},{"issue":"2","key":"2021011515545499300_ocaa264-B35","doi-asserted-by":"crossref","first-page":"305","DOI":"10.1136\/amiajnl-2012-001055","article-title":"Understanding and preventing wrong-patient electronic orders: a randomized controlled trial","volume":"20","author":"Adelman","year":"2013","journal-title":"J Am Med Inform Assoc"},{"issue":"3","key":"2021011515545499300_ocaa264-B36","doi-asserted-by":"crossref","first-page":"477","DOI":"10.1136\/amiajnl-2012-001555","article-title":"Indication-based prescribing prevents wrong-patient medication errors in computerized provider order entry (CPOE)","volume":"20","author":"Galanter","year":"2013","journal-title":"J Am Med Inform Assoc"},{"issue":"7","key":"2021011515545499300_ocaa264-B37","doi-asserted-by":"crossref","first-page":"e101977","DOI":"10.1371\/journal.pone.0101977","article-title":"Indication alerts intercept drug name confusion errors during computerized entry of medication orders","volume":"9","author":"Galanter","year":"2014","journal-title":"PLoS One"},{"issue":"1","key":"2021011515545499300_ocaa264-B38","doi-asserted-by":"crossref","first-page":"21","DOI":"10.1080\/00140139.2010.535022","article-title":"The influence of \u2018Tall Man\u2019 lettering on errors of visual perception in the recognition of written drug names","volume":"54","author":"Darker","year":"2011","journal-title":"Ergonomics"},{"issue":"8","key":"2021011515545499300_ocaa264-B39","doi-asserted-by":"crossref","first-page":"677","DOI":"10.2165\/11532360-000000000-00000","article-title":"The influence of tall man lettering on drug name confusion","volume":"33","author":"Filik","year":"2010","journal-title":"Drug Saf"},{"issue":"1","key":"2021011515545499300_ocaa264-B40","doi-asserted-by":"crossref","first-page":"e15","DOI":"10.2196\/humanfactors.5320","article-title":"How regrouping alerts in computerized physician order entry layout influences physicians\u2019 prescription behavior: results of a crossover randomized trial","volume":"3","author":"Wipfli","year":"2016","journal-title":"JMIR Hum Factors"},{"issue":"6","key":"2021011515545499300_ocaa264-B41","doi-asserted-by":"crossref","first-page":"739","DOI":"10.1093\/jamia\/ocx099","article-title":"Effect of number of open charts on intercepted wrong-patient medication orders in an emergency department","volume":"25","author":"Kannampallil","year":"2018","journal-title":"J Am Med Inform Assoc"},{"issue":"6","key":"2021011515545499300_ocaa264-B42","doi-asserted-by":"crossref","first-page":"865","DOI":"10.1016\/j.jpeds.2008.12.022","article-title":"Preprinted order sets as a safety intervention in pediatric sedation","volume":"154","author":"Broussard","year":"2009","journal-title":"J Pediatr"},{"issue":"4","key":"2021011515545499300_ocaa264-B43","doi-asserted-by":"crossref","first-page":"322","DOI":"10.1197\/jamia.M1090","article-title":"Preparation and use of preconstructed orders, order sets, and order menus in a computerized provider order entry system","volume":"10","author":"Payne","year":"2003","journal-title":"J Am Med Inform Assoc"},{"issue":"18","key":"2021011515545499300_ocaa264-B44","doi-asserted-by":"crossref","first-page":"1780","DOI":"10.1001\/jama.2019.3698","article-title":"Effect of restriction of the number of concurrently open records in an electronic health record on wrong-patient order errors: a randomized clinical trial","volume":"321","author":"Adelman","year":"2019","journal-title":"JAMA"},{"issue":"4","key":"2021011515545499300_ocaa264-B45","doi-asserted-by":"crossref","first-page":"213","DOI":"10.1136\/bmjqs-2015-004929","article-title":"Does Tall Man lettering prevent drug name confusion errors? Incomplete and conflicting evidence suggest need for definitive study","volume":"25","author":"Lambert","year":"2016","journal-title":"BMJ Qual Saf"},{"issue":"4","key":"2021011515545499300_ocaa264-B46","doi-asserted-by":"crossref","first-page":"233","DOI":"10.1136\/bmjqs-2015-004562","article-title":"Tall Man lettering and potential prescription errors: a time series analysis of 42 children's hospitals in the USA over 9 years","volume":"25","author":"Zhong","year":"2016","journal-title":"BMJ Qual Saf"},{"issue":"6","key":"2021011515545499300_ocaa264-B47","first-page":"377","article-title":"Medical error reporting attitudes of healthcare personnel, barriers and solutions: a literature review","volume":"5","author":"Unal","year":"2016","journal-title":"J Nurs Care"},{"issue":"1","key":"2021011515545499300_ocaa264-B48","doi-asserted-by":"crossref","first-page":"17","DOI":"10.1016\/j.outlook.2009.06.001","article-title":"Factors determining hospital nurses' failures in reporting medication errors in Taiwan","volume":"58","author":"Chiang","year":"2010","journal-title":"Nursing Outlook"},{"issue":"1","key":"2021011515545499300_ocaa264-B49","doi-asserted-by":"crossref","first-page":"51","DOI":"10.1016\/j.jcjq.2019.10.008","article-title":"AHRQ series on improving translation of evidence: progress and promise in supporting learning health systems","volume":"46","author":"Guise","year":"2020","journal-title":"Jt Commission J Qual Patient Saf"},{"issue":"3","key":"2021011515545499300_ocaa264-B50","doi-asserted-by":"crossref","first-page":"207","DOI":"10.7326\/0003-4819-157-3-201208070-00012","article-title":"Implementing the learning health system: from concept to action","volume":"157","author":"Greene","year":"2012","journal-title":"Ann Intern Med"},{"issue":"15","key":"2021011515545499300_ocaa264-B51","doi-asserted-by":"crossref","first-page":"1200","DOI":"10.1001\/jama.279.15.1200","article-title":"Incidence of adverse drug reactions in hospitalized patients: a meta-analysis of prospective studies","volume":"279","author":"Lazarou","year":"1998","journal-title":"JAMA"},{"issue":"5","key":"2021011515545499300_ocaa264-B52","doi-asserted-by":"crossref","first-page":"613","DOI":"10.1197\/jamia.M3050","article-title":"Does computerized provider order entry reduce prescribing errors for hospital inpatients? A systematic review","volume":"16","author":"Reckmann","year":"2009","journal-title":"J Am Med Inform Assoc"},{"issue":"4","key":"2021011515545499300_ocaa264-B53","doi-asserted-by":"crossref","first-page":"722","DOI":"10.1542\/peds.111.4.722","article-title":"Prioritizing strategies for preventing medication errors and adverse drug events in pediatric inpatients","volume":"111","author":"Fortescue","year":"2003","journal-title":"Pediatrics"}],"container-title":["Journal of the American Medical Informatics Association"],"original-title":[],"language":"en","link":[{"URL":"http:\/\/academic.oup.com\/jamia\/article-pdf\/28\/1\/86\/35885549\/ocaa264.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"http:\/\/academic.oup.com\/jamia\/article-pdf\/28\/1\/86\/35885549\/ocaa264.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2021,1,15]],"date-time":"2021-01-15T21:04:23Z","timestamp":1610744663000},"score":1,"resource":{"primary":{"URL":"https:\/\/academic.oup.com\/jamia\/article\/28\/1\/86\/5998354"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2020,11,22]]},"references-count":53,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2020,11,22]]},"published-print":{"date-parts":[[2021,1,15]]}},"URL":"https:\/\/doi.org\/10.1093\/jamia\/ocaa264","relation":{},"ISSN":["1527-974X"],"issn-type":[{"value":"1527-974X","type":"electronic"}],"subject":[],"published-other":{"date-parts":[[2021,1]]},"published":{"date-parts":[[2020,11,22]]}}}