Hospital EHRs Miss Many Potential Medication Errors: Study

Despite modest improvements in their safety performance over the past decade, the electronic health record (EHR) systems used in US hospitals fail to detect up to 1 in 3 potentially harmful drug interactions and other medication errors, according to researchers.

They analyzed 10 years of data from the Health IT Safety Test, which has been endorsed by the National Quality Forum. The Leapfrog Group, an employer watchdog organization, has provided this test to hospitals since 2009 as part of its annual hospital survey.

David C. Classen, MD, MS, from the Division of Clinical Epidemiology at the University of Utah School of Medicine, Salt Lake City, and colleagues published their findings online May 29 in JAMA Open Network.

The study sample included 2314 hospitals that had tested their EHRs at least once between 2009 and 2018. In these tests, using simulated patients, clinicians entered medication orders that had either injured or killed patients previously to evaluate how well hospital EHRs could identify orders with the potential for patient harm.

All of the hospital EHRs included computerized physician order entry (CPOE) and clinical decision support (CDS) features to improve medication safety. The order types were divided into basic and advanced categories. In the first category were orders in which adverse drug events could be prevented by using basic CDS (ie, drug-allergy, drug-route, drug-drug, drug-dose for single doses, and therapeutic duplication contraindications). The second category required advanced CDS to trigger alerts about potential adverse drug events (ie, drug-laboratory, drug-dose for daily doses, drug-age, drug-diagnosis, and corollary order contraindications).

The test’s primary outcome measure was whether the hospital EHR system correctly generated an alert, a warning, or a soft or hard stop after a clinician entered a test order that could have caused an adverse drug event. The performance scores in the study represent the percentage of cases in which this happened.

During the study period, mean hospital scores on the overall test, which included both basic and advanced CDS, increased from 53.9% in 2009 to 65.6% in 2018. Mean scores in the categories using basic CDS increased from 69.8% in 2009 to 85.6% in 2018. For the categories representing advanced CDS, the average score increased from 29.6% in 2009 to 46.1% in 2018.

Too Little Improvement

EHRs improved in their ability to detect errors, especially in the areas supported by basic CDS. Moreover, the number of institutions taking the test has increased tenfold during the past decade; however, the progress made to date falls far short of the expectations for safety with electronic ordering systems.

“EHRs are supposed to ensure safe use of medications in hospitals,” said Classen, the study’s corresponding author and a professor of internal medicine at University of Utah Health, in a news release. “But they’re not doing that. In any other industry, this degree of software failure wouldn’t be tolerated. 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.”