An analysis of Pennsylvania’s statewide system for reporting patient-safety incidents and serious events has yielded thousands of error reports that suggest electronic health records (EHRs) sometimes may cause drug mishaps rather than prevent them.

“It’s the first time that I’m aware of that someone looked through a major reporting program to determine if the role of EHRs contributed to events,” said Matthew Grissinger, RPh, the director of error reporting programs at the Institute for Safe Medication Practices, in Horsham, Pa., who was not involved in the study. “The biggest strength [of the study] is that [the investigators] rolled up their sleeves, got their hands dirty and read the reports.”

The researchers queried the Pennsylvania Patient Safety Reporting System (PA-PSRS) database using EHR-related search terms; the query returned 8,003 reports from June 2, 2004, through May 18, 2012. After the reports were winnowed, 3,099 were confirmed as relevant to EHRs. Of these, 2,763 (89%) were classified as “event, no harm,” such as when an error occurred without an adverse outcome for the patient. An additional 320 reports (10%) were classified as “unsafe conditions,” which did not result in patient harm, according to the investigators (Pa Patient Saf Advis 2012;9:113-121).

fifteen reports (0.48%) involved temporary harm to the patient. In these cases, the harm was caused by “entering wrong medication data (n=6), administering the wrong medication (n=3), ignoring a documented allergy (n=2), failing to enter lab tests (n=2) and failing to document (n=2).” One event report involved significant harm, via failure to document an allergy to penicillin.

The proportion of health IT-related events that involved patient harm in the study is similar to the rates of harm seen with medication error reports, noted William M. Marella, MBA, the program director of the Pennsylvania Patient Safety Authority, in Harrisburg, and one of two authors of the study.

Digging a bit deeper into the findings of the report, most (81%) of the documented safety events involved medication errors, such as those caused by wrong drug, dose, time, patient or route (50%). Many of the events involved complications of procedures, treatments or tests (13%).

Some reports were tagged with more than one problem type (e.g., data entered into wrong fields), resulting in a total of 3,946 problems identified from the 3,099 reports. Many problems were related to wrong input (n=1,867), such as transposition or transcription errors, entry of incorrect patient parameters (e.g., weight), and even entry of the wrong physician name.

Study Weaknesses

Erin Sparnon, MEng, a senior patient safety analyst at the Pennsylvania Patient Safety Authority and the other author of the study, said its major limitation was “lack of awareness on the part of reporting health caregivers that health IT could contribute to an event. Unless the reporter used specific queried health IT-related terms, we would have missed it. It suggests there may have been more health IT events.”

Mr. Grissinger said that the major limitation “is the data itself.” For example, “if you selected the wrong patient or the wrong drug, [that type of error report] doesn’t tell you the manufacturer of the system, what did the screen look like or other contributing factors. You don’t get a complete picture.”

The data in the study were not tagged by caregiver, so pharmacist-related events could not be isolated, Ms. Sparnon noted. However, Mr. Grissinger said selecting wrong patients and wrong drugs were common medication errors involving pharmacy order entry programs. To reduce errors related to EHRs, he recommended the following: “Test the pharmacy order entry system. Test it to know what it can and cannot do. Pharmacists get a lot of drug interaction alerts; as a result, you can get alert fatigue. Consider a process of reviewing alerts over a month for orders that have been overridden. Clean house by reviewing the drug dictionary in the pharmacy order entry system to remove unnecessary or unused drug listings once a year. Use tall man lettering to make one drug name look different from another.”

EHRs present certain risks over paper records, Mr. Grissinger added. “Leaders may not realize the level or number of staff that it takes to keep health IT updated and improved. The risk is not knowing what has to be done.” He added that a bigger risk was a mix of paper and electronic order entry—“a chaotic, hybrid system, where orders can be missed. I am far more concerned about that.”

Asked how their study should affect clinical practice, Ms. Sparnon said it should “raise awareness that health IT can play a role in medical error.” Mr. Marella said it should “raise the question of how to modify the system so a common format for health IT is developed.”



Mr. Grissinger reported serving as a manager of medication safety analysis for the Pennsylvania Patient Safety Authority. Mr. Marella and Ms. Sparnon reported no relevant financial conflicts of interest.