Medication errors, handoff processes and information quality : A community hospital case study

Purpose – The purpose of this paper is to examine how clinical handoffs affect clinical information quality (IQ) and medication administration quality. Design/methodology/approach – A case study was conducted in a US hospital. The authors applied a business process management (BPM) perspective to analyze an end‐to‐end medication administration process and related handoffs, and accounting control theory (ACT) to examine the impact of handoffs on IQ and medication errors. Findings – The study reveals how handoffs can lead to medication errors (by passing information that is not complete, accurate, timely or valid) and can help reduce errors (by preventing, detecting and correcting information quality flaws or prior clinical mistakes). Research limitations/implications – The paper reports on one case study on one hospital unit. Future studies can investigate the impact of clinical IQ on patient safety across the multitude of health information technologies (e.g. computerized provider order entry (CPOE), electronic medication administration records (EMAR), and barcode medication administration systems (BCMA)) and approaches to process design and support (e.g. use of clinical pathways and checklists). Practical implications – The findings can contribute to more successful design, implementation and evaluation of medication administration and other clinical processes, ultimately improving patient safety. Originality/value – The paper's main contribution is the use of accounting control theory to systematically focus on IQ to evaluate and improve end‐to‐end medical administration processes.