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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
  1. Hajar Mozaffar1,
  2. Kathrin M Cresswell2,
  3. Robin Williams3,
  4. David W Bates4,
  5. Aziz Sheikh2
  1. 1 Business School, University of Edinburgh, Edinburgh, UK
  2. 2 Centre for Medical informatics, Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Edinburgh, UK
  3. 3 Institute for the Study of Science, Technology and Innovation, The University of Edinburgh, Edinburgh, UK
  4. 4 Brigham and Women's Hospital, Boston, Massachusetts, USA
  5. 5 Division of Community Health Sciences, University of Edinburgh, Edinburgh, UK
  1. Correspondence to Dr Hajar Mozaffar, Business School, University of Edinburgh, 29 Buccleuch Place, Edinburgh EH8 9JS, UK; h.mozaffar{at}, h.mozaffar{at}


Objective Hospital electronic prescribing (ePrescribing) systems offer a wide range of patient safety benefits. Like other hospital health information technology interventions, however, they may also introduce new areas of risk. Despite recent advances in identifying these risks, the development and use of ePrescribing systems is still leading to numerous unintended consequences, which may undermine improvement and threaten patient safety. These negative consequences need to be analysed in the design, implementation and use of these systems. We therefore aimed to understand the roots of these reported threats and identify candidate avoidance/mitigation strategies.

Methods We analysed a longitudinal, qualitative study of the implementation and adoption of ePrescribing systems in six English hospitals, each being conceptualised as a case study. Data included semistructured interviews, observations of implementation meetings and system use, and a collection of relevant documents. We analysed data first within and then across the case studies.

Results Our dataset included 214 interviews, 24 observations and 18 documents. We developed a taxonomy of factors underlying unintended safety threats in: (1) suboptimal system design, including lack of support for complex medication administration regimens, lack of effective integration between different systems, and lack of effective automated decision support tools; (2) inappropriate use of systems—in particular, too much reliance on the system and introduction of workarounds; and (3) suboptimal implementation strategies resulting from partial roll-outs/dual systems and lack of appropriate training. We have identified a number of system and organisational strategies that could potentially avoid or reduce these risks.

Conclusions Imperfections in the design, implementation and use of ePrescribing systems can give rise to unintended consequences, including safety threats. Hospitals and suppliers need to implement short- and long-term strategies in terms of the technology and organisation to minimise the unintended safety risks.

  • Decision support, computerized
  • Information technology
  • Patient safety

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  • Contributors AS and RW conceived the study. HM and KMC performed the data collection. HM led the data analysis and wrote the paper. HM, KMC and RW performed further data analysis. All authors critically commented on the paper. All authors read and approved the final manuscript.

  • Funding This article has drawn on a programme of independent research funded by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research scheme (RP-PG-1209-10099). The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health. AS is supported by the Farr Institute.

  • Competing interests None declared.

  • Ethics approval The University of Edinburgh's Research Ethics Committee.

  • Provenance and peer review Not commissioned; externally peer reviewed.