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EHRs Fail to Detect Up to One-third of Medication Errors

Hospital Safety Insider, June 11, 2020

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By John Commins

One of the big promises made in the nation’s decade-long, multibillion-dollar push to expand the use of electronic health records was that it would reduce medication errors.

Now, a new study published in JAMA Network Open suggests that EHRs are not delivering on that promise.

Researchers at the University of Utah Health, Harvard University, and Brigham and Women’s Hospital in Boston found that the most commonly used EHRs in hospitals across the nation fail to detect up to 33% of potentially dangerous drug interactions and other medication errors that could harm or kill patients.

“EHRs are supposed to ensure safe use of medications in hospitals,” said study corresponding author David C. Classen, MD, a professor of internal medicine at U of U Health. “They’re not doing that.”

“In any other industry, this degree of software failure wouldn’t be tolerated,” Classen said. “You would never get on an airplane, for instance, if an airline could only promise it could get you to your destination safely two-thirds of the time.”

To determine the effectiveness of EHRs, the researchers looked at results from an EHR safety evaluation tool called Leapfrog CPOE EHR test. The test simulates drug orders that have the potential to injure patients, and almost all of the scenarios the researchers considered were based on actual adverse drug events that harmed or killed patients in the real world.

In one scenario, for example, a 52-year-old patient with a history of deep vein thrombosis was admitted to the hospital with pneumonia.

The patient was given warfarin three times a day, triple the dosage she took before admission, which went undetected by the hospital’s EHR system for five days. The patient hemorrhaged and died of causes directly related to the wafarin overdose.

Scenarios such as this were fed into EHR systems at 2,314 hospitals nationwide from 2009 through 2018 to see if their systems would perform better.

The researchers found that, in 2009, these systems correctly issued warnings or alerts about potential medication problems only 54% of the time. By 2018, EHRs detected about 66% of these errors.

Classen said problem is compounded because hospitals often customize their EHR software to meet their own needs. That makes it difficult to keep up with changes in drug safety. Those limitations mean that a serious drug interaction that would trigger EHR warnings at one hospital might not at another one.

John Commins is a content specialist and online news editor for HealthLeaders, a Simplify Compliance brand.

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