title: Clinicians were oblivious to incorrect logging of test dates and the associated risks in an online pathology application: a case study.
abstract: BACKGROUND
  UK primary care physicians receive their laboratory test results electronically. This study reports a computerised physician order entry (CPOE) system error in the pathology test request date that went unnoticed in family practices.
  
  
  METHODS
  We conducted a case study using a causation of risk theoretical framework; comprising interviews with clinicians and the manufacturer to explore the identification of and reaction to the error. The primary outcome was the evolution and recognition of and response to the problem. The secondary outcome was to identify other issues with this system noted by users.
  
  
  RESULTS
  The problem was defined as the incorrect logging of test dates ordered through a CPOE system. The system assigned the test request date to the results, hence a blood test taken after a therapeutic intervention (e.g. an increase in cholesterol-lowering therapy) would appear in the computerised medical record as though it had been tested prior to the increase in treatment. This case demonstrates that: the manufacturers failed to understand family physician workflow; regulation of medical software did not prevent the error; and inherent user trust in technology exacerbated this problem. It took three months before users in two practices independently noted the date errors.
  
  
  CONCLUSIONS
  This case illustrates how users take software on trust and suppliers fail to make provision for risks associated with new software. Resulting errors led to inappropriate prescribing, follow-up, costs and risk. The evaluation of such devices should include utilising risk management processes (RMP) to minimise and manage potential risk.
authors.affiliation: Department of Health Care Management and Policy, University of Surrey, Guildford, UK.
authors.forename: Amber
authors.initials: A
authors.lastname: Appleton
authors.forename: Khaled
authors.initials: K
authors.lastname: Sadek
authors.forename: Ian G J
authors.initials: IG
authors.lastname: Dawson
authors.forename: Simon
authors.initials: S
authors.lastname: de Lusignan
mesh_terms: D004777:Environment; D005568:Forms and Records Control / Q000458:organization & administration*; D006801:Humans; D020407:Internet; D050316:Medical Order Entry Systems / Q000458:organization & administration*; D019982:Organizational Case Studies; D010336:Pathology / Q000458:organization & administration*; D012307:Risk Factors; D012985:Software Design; D013997:Time Factors; D006113:United Kingdom