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PSNet: Patient Safety Network
Journal Article

Exploring the roots of unintended safety threats associated with the introduction of hospital ePrescribing systems and candidate avoidance and/or mitigation strategies: a qualitative study.

Mozaffar H, Cresswell KM, Williams R, et al. BMJ quality & safety. 2017;26:722-733.

Although computerized provider order entry is known to reduce medication errors, previous research has demonstrated that electronic prescribing can introduce new medication safety risks. This observational qualitative study of electronic prescribing at six British hospitals included direct observation, interviews, and analysis of implementation documents. Investigators determined multiple unintended consequences of electronic prescribing, at every stage of use, and identified design flaws in electronic prescribing platforms. Suboptimal implementation of electronic prescribing, with partial functionality and insufficient training, increased risk of errors. Once electronic prescribing was in place, prescribers started using workarounds and relied too much on the prescribing platform. The authors call for design and organizational strategies to mitigate these safety concerns. A past WebM&M commentary described a medication error related to electronic prescribing.