0aba0e57__of_Health_Information_Systems__Name
[Year] July 2005 [Description] The authors used a novel approach to analyze a dosing error related to computer-based ordering of potassium chloride (KCl). In this case, the error was the product of faults in interaction among human and system agents that methods limited in scope to their distinct analytical domains would not identify. The authors characterized errors in several converging aspects of the drug ordering process: confusing on-screen laboratory results review, system usability difficulties, user training problems, and suboptimal clinical system safeguards that all contributed to a serious dosing error. [References] Horsky J et al. Comprehensive analysis of a medication dosing error related to CPOE. J Am Med Inform Assoc. 2005 Jul-Aug;12(4):377-82. [Name] 
Dosing error related to CPOE
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