An analysis of electronic health record-related patient safety concerns
Open accessAbstract
OBJECTIVE: A recent Institute of Medicine report called for attention to safety issues related to electronic health records (EHRs). We analyzed EHR-related safety concerns reported within a large, integrated healthcare system. METHODS: The Informatics Patient Safety Office of the Veterans Health Administration (VA) maintains a non-punitive, voluntary reporting system to collect and investigate EHR-related safety concerns (ie, adverse events, potential events, and near misses). We analyzed completed investigations using an eight-dimension sociotechnical conceptual model that accounted for both technical and non-technical dimensions of safety. Using the framework analysis approach to qualitative data, we identified emergent and recurring safety concerns common to multiple reports. RESULTS: We extracted 100 consecutive, unique, closed investigations between August 2009 and May 2013 from 344 reported incidents. Seventy-four involved unsafe technology and 25 involved unsafe use of technology. A majority (70%) involved two or more model dimensions. Most often, non-technical dimensions such as workflow, policies, and personnel interacted in a complex fashion with technical dimensions such as software/hardware, content, and user interface to produce safety concerns. Most (94%) safety concerns related to either unmet data-display needs in the EHR (ie, displayed information available to the end user failed to reduce uncertainty or led to increased potential for patient harm), software upgrades or modifications, data transmission between components of the EHR, or 'hidden dependencies' within the EHR. DISCUSSION: EHR-related safety concerns involving both unsafe technology and unsafe use of technology persist long after 'go-live' and despite the sophisticated EHR infrastructure represented in our data source. Currently, few healthcare institutions have reporting and analysis capabilities similar to the VA. CONCLUSIONS: Because EHR-related safety concerns have complex sociotechnical origins, institutions with long-standing as well as recent EHR implementations should build a robust infrastructure to monitor and learn from them.
AI snapshot
Written from the paper’s full text.
TL;DR
Analysis of 100 closed VA investigations of EHR-related safety concerns found that most involved unsafe technology and complex interactions across sociotechnical dimensions. Four recurring concern types accounted for 94% of incidents, showing that EHR safety concerns persist long after go-live even in a mature EHR system.
Key findings
- Of 100 consecutive, unique, closed investigations from August 2009 to May 2013, 74 involved unsafe technology (phase 1), 25 involved unsafe use of technology (phase 2), and 1 involved lack of monitoring (phase 3); 70% involved two or more sociotechnical model dimensions.
- Four concern types accounted for 94% of incidents: unmet display needs (n=36), software modifications/upgrades (n=24), system–system interface failures (n=17), and hidden dependencies in distributed systems (n=17).
- The most commonly involved sociotechnical dimensions were hardware/software (76), clinical content (38), workflow/communication (35), human–computer interface (29), and people (20).
- Incidents came from 55 unique VA facilities; IPS safety scores were low for 48 investigations, intermediate for 38, and high for 14.
Methods
- Retrospective qualitative analysis of completed EHR-related safety investigations from the Veterans Health Administration Informatics Patient Safety Office, using 100 consecutive unique closed investigations extracted from 344 reported incidents.
- Used framework analysis guided by Sittig and Singh’s eight-dimension sociotechnical model and three EHR safety phases; two authors independently indexed concerns, resolving discrepancies by consensus.
- Coded narrative investigation reports in Atlas.ti V.6.2 and arranged data in Microsoft Excel; no inter-rater reliability was reported because the aim was descriptive.
Limitations
- The paper states all incidents involved the same EHR within a single, albeit very large, healthcare system; findings may not generalize to institutions with different organizational characteristics, EHR infrastructure, or reporting mechanisms.
- The paper states the data ranged from unsafe conditions to patient harm, did not analyze additional patient outcome data, and that reporting captures fewer than 10% of medical errors, so prevalence rates cannot be calculated.
- The paper notes self-reported data may be limited by recall bias or reporter knowledge; evident from the text, the retrospective voluntary reporting system and exclusion of duplicate or comingled-record concerns may underrepresent the full universe of EHR-related safety concerns.
Model-written summary. Check it against the paper before relying on it.
Integrity signals
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Cites
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Claims the paper makes
0 of 50 cited sources checked · 0 supported · 0 flagged
- Findingown data
Hidden dependency incidents spanned both phase 1 (11 incidents) and phase 2 (6 incidents) of EHR safety.
“These incidents also spanned both phase 1 (11 incidents) and phase 2 (6 incidents) of EHR safety.”
Quote in the paperNot a substantial claim - Findingown data
Across the 36 unmet display concerns, contributory dimensions were hardware/software (22), human-computer interface (22), workflow/communication (10), clinical content (9), people (9), organizational policies and procedures (2), and system measurement and monitoring (1).
“Across the 36 concerns within this concern type, the contributory dimensions were hardware and software (22 incidents), human–computer interface (22 incidents), workflow and communication (10 incidents), clinical content (9 incidents), people (9 incidents), organizational policies and procedures (2 incidents), and system measurement and monitoring (1 incident).”
Quote in the paperNot a substantial claim - Findingown data
Phase 2 concerns most commonly involved people, clinical content, workflow and communication, and human-computer interface.
“One-quarter were classified as phase 2 (ie, unsafe EHR use) and most commonly involved the dimensions of people, clinical content, workflow and communication, and human–computer interface.”
Quote in the paperNot a substantial claim - Findingown data
A pharmacist made a data entry error while approving the order for a larger-than-usual amount of diuretic.
“First, a pharmacist made a data entry error while approving the order for a larger-than-usual amount of diuretic.”
Quote in the paperNot a substantial claim - Findingown data
All four types of safety concerns affected, or had the potential to affect, multiple patients.
“All four types of safety concerns affected, or had the potential to affect, multiple patients, although we did not further analyze outcome data except as noted below.”
Quote in the paperNot a substantial claim
- Findingown data
Sociotechnical dimensions of phase 1 concerns most commonly involved hardware and software, workflow and communication, and clinical content.
“Sociotechnical dimensions of phase 1 concerns most commonly involved hardware and software, workflow and communication, and clinical content.”
Quote in the paperNot a substantial claim - Findingreasoning
The over-ride released the incorrect dose for administration by nursing staff.
“The over-ride released the incorrect dose for administration by nursing staff.”
Quote in the paperNot a substantial claim - Findingreasoning
Owing to diminished user confidence in the warning's reliability, the warning was over-ridden.
“Owing to diminished user confidence in the warning's reliability, the warning was over-ridden.”
Quote in the paperNot a substantial claim - Findingown data
Most (22 of 36) unmet display concerns were classified as phase 1, followed by 13 phase 2, and one phase 3.
“Most (22 of 36) of these concerns were classified as phase 1 issues, followed by 13 phase 2, and one phase 3.”
Quote in the paperNot a substantial claim - Findingnone given
Safety concerns involving hidden dependencies and system-system interfaces are not mutually exclusive.
“Safety concerns involving hidden dependencies and system–system interfaces are not mutually exclusive.”
Quote in the paperNot a substantial claim - Findingown data
One configuration error involved a disease management package that, after local implementation, was found to have erroneously escalated user privileges to place and sign orders.
“One configuration error involved a disease management package that, after local implementation, was found to have erroneously escalated user privileges to place and sign orders.”
Quote in the paperNot a substantial claim - Findingown data
One-quarter of safety concerns were classified as phase 2, unsafe EHR use.
“One-quarter were classified as phase 2 (ie, unsafe EHR use) and most commonly involved the dimensions of people, clinical content, workflow and communication, and human–computer interface.”
Quote in the paperNot a substantial claim - Findingown data
The authors analyzed 17 cases where the primary safety concern involved system-system interfaces.
“We analyzed 17 cases where the primary safety concern involved system–system interfaces, the means by which information is transferred from one EHR component to another.”
Quote in the paperNot a substantial claim - Findingown data
The authors extracted 100 consecutive, unique, closed investigations between August 2009 and May 2013 from 344 reported incidents.
“We extracted 100 consecutive, unique, closed investigations between August 2009 and May 2013 from 344 reported incidents.”
- Also stated in: § Results · plain
“We extracted 100 consecutive, unique, closed investigations between August 2009 and May 2013 from 344 reported incidents.”
Quote in the paperSubstantial claim - Also stated in: § Results · plain
- Findingcitation
Patient safety concerns in the system-system interface category often involved maintaining a unique patient's context.
“Patient safety concerns in this category often involved maintaining a unique patient's context, a process designed to keep various individual EHR components centered on a single patient as the user traverses the EHR components.”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [51] Sittig DF Teich JM Yungton JA . Preserving context in a multi-tasking clinical environment: a pilot implementation. Proc AMIA Annu Fall Symp 1997; 784–8.
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- Findingown data
The authors analyzed 100 unique, consecutive investigations of EHR-related safety concerns reported to and investigated by the VA's Informatics Patient Safety Office.
“We analyzed 100 unique, consecutive investigations of EHR-related safety concerns reported to and investigated by the VA's Informatics Patient Safety Office.”
Quote in the paperSubstantial claim - Findingown data
The second most common concern type involved upgrades to the EHR or one of its components, or improperly configured software, with 24 incidents.
“The second most common concern type involved upgrades to the EHR or one of its components, or improperly configured software (24 incidents).”
Quote in the paperNot a substantial claim - Findingown data
One incident described an inadvertent change to a configuration file during an update to the EHR that prevented the EHR from communicating with the printing system used to label laboratory specimens.
“For example, one incident described an inadvertent change to a configuration file during an update to the EHR that prevented the EHR from communicating with the printing system used to label laboratory specimens.”
Quote in the paperNot a substantial claim - Findingown data
Main contributing sociotechnical dimensions of the software modification concern type were hardware/software (21), clinical content (10), and workflow/communication (5).
“The main contributing sociotechnical dimensions of this concern type were hardware and software (21 incidents), clinical content (10 incidents), and workflow and communication (5 incidents).”
Quote in the paperNot a substantial claim - Findingown data
One incident described a patient administered a dose of a diuretic that exceeded the prescribed amount.
“As an example, one incident described a situation in which a patient was administered a dose of a diuretic that exceeded the prescribed amount.”
Quote in the paperNot a substantial claim - Findingown data
Approximately three-quarters of safety concerns were categorized as phase 1, concerns related to unsafe technology.
“Seventy-four involved unsafe technology and 25 involved unsafe use of technology.”
- Also stated in: § Results · plain
“Approximately three-quarters of safety concerns were categorized as phase 1 (ie, concerns related to unsafe technology).”
Quote in the paperNot a substantial claim - Also stated in: § Results · plain
- Findingown data
Only one safety concern involving phase 3, failure to use the EHR to monitor patient safety, was represented in the analysis.
“Only one safety concern involving phase 3 (ie, failure to use the EHR to monitor patient safety) was represented in our analysis.”
Quote in the paperNot a substantial claim - Findingown data
Safety concerns typically emerged from complex interactions of multiple sociotechnical aspects of the EHR system.
“Safety concerns typically emerged from complex interactions of multiple sociotechnical aspects of the EHR system.”
Quote in the paperSubstantial claim - Findingown data
All incidents of the system-system interface concern category were coded as phase 1 EHR use.
“All incidents of this concern category were coded as phase 1 EHR use.”
Quote in the paperNot a substantial claim - Findingown data
The four types of concerns accounted for 94% of the incidents analyzed.
“Most (94%) safety concerns related to either unmet data-display needs in the EHR (ie, displayed information available to the end user failed to reduce uncertainty or led to increased potential for patient harm), software upgrades or modifications, data transmission between components of the EHR, or ‘hidden dependencies’ within the EHR.”
- Also stated in: § Results · plain
“Table 2 provides definitions and examples of these four types of concerns, which accounted for 94% of the incidents analyzed.”
Quote in the paperNot a substantial claim - Also stated in: § Results · plain
- Findingown data
Unmet display needs was the most common type of concern observed, with 36 incidents.
“Unmet display needs was the most common type of concern observed (36 incidents).”
Quote in the paperNot a substantial claim - Findingnone given
A majority of reported incidents were phase 1 or unsafe technology.
“Having a mature EHR system clearly does not eliminate EHR-related safety concerns, and a majority of reported incidents were phase 1 or unsafe technology.”
Quote in the paperSubstantial claim - Findingown data
Some safety concerns had relatively straightforward origins, such as simultaneous use of multiple instances of an EHR application by a single user, leading to order entry on the wrong patient.
“Some safety concerns had relatively straightforward origins, such as simultaneous use of multiple instances of an EHR application by a single user, leading to order entry on the wrong patient.”
Quote in the paperNot a substantial claim - Findingown data
Even within a well-established EHR infrastructure, many significant EHR-related safety concerns related to both unsafe technology and unsafe use of technology remain.
“We found that, even within a well-established EHR infrastructure, many significant EHR-related safety concerns related to both unsafe technology and unsafe use of technology remain.”
Quote in the paperSubstantial claim - Findingown data
All four emergent safety concerns affected, or had the potential to affect, multiple patients.
“All four emergent safety concerns affected, or had the potential to affect, multiple patients, but we did not analyze additional data on patient outcomes as a result of these concerns.”
Quote in the paperNot a substantial claim - Findingown data
Other problems had more complex origins, such as user misinterpretation of information presented through the EHR's user interface.
“Other problems had more complex origins, such as user misinterpretation of information presented through the EHR's user interface.”
Quote in the paperNot a substantial claim - Premisecitation
Detecting and preventing EHR-related safety concerns is challenging because concerns are often multifaceted, involving unsafe technological features, user behaviors, organizational characteristics, and rules and regulations.
“Detecting and preventing EHR-related safety concerns is challenging because concerns are often multifaceted, involving not only potentially unsafe technological features of the EHR but also EHR user behaviors, organizational characteristics, and rules and regulations that guide EHR-related activities.”
Quote in the paperSubstantial claim0 of 4 sources checked- cites [24] source
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- cites [25] source
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- cites [26] Harrison MI Henriksen K Hughes RG . Improving the health care work environment: a sociotechnical systems approach. Jt Comm J Qual Patient Saf 2007;33 (11 Suppl):3–6, 1. source
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- cites [27] source
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- Premisecitation
Conceptual frameworks or models have been developed to incorporate the breadth of technical and non-technical factors into the analysis of EHR safety and effectiveness.
“In addition, conceptual frameworks or models have been developed to incorporate the breadth of technical and non-technical factors into the analysis of EHR safety and effectiveness.21 25 27 32 33”
Quote in the paperNot a substantial claim0 of 3 sources checked- cites [21] Meeks DW Takian A Sittig DF . Exploring the sociotechnical intersection of patient safety and electronic health record implementation. J Am Med Inform Assoc 2014;21(e1) e28 34. source
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- Premisecitation
A few studies have attempted to quantify and classify EHR-related safety concerns by mining patient safety incident reporting databases.
“A few studies have attempted to quantify and classify EHR-related safety concerns by mining patient safety incident reporting databases.18 29–31”
Quote in the paperNot a substantial claim0 of 4 sources checked- cites [18] source
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- cites [31] Sparnon E Marella WM . The role of the electronic health record in patient safety events. Harrisburg, PA: Pennsylvania Patient Safety Authority; 2012.
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- Premisecitation
Despite a clear need to define and understand EHR-related safety concerns, data describing their nature and magnitude are scarce.
“Despite a clear need to define and understand EHR-related safety concerns,28 data that describe the nature and magnitude of these concerns are scarce.”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [28] Health Information Technology Safety Action & Surveillance Plan. The Office for the National Coordinator of Health Information Technology 2013 July 2 [cited 2013 Jul 11]; http://www.healthit.gov/sites/default/files/safety_plan_master.pdf
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- Premisecitation
Emerging evidence suggests that health information technology may cause new patient safety concerns and other unintended consequences due to usability issues, disruptions of clinical processes, and unsafe workarounds.
“However, emerging evidence suggests that HIT may cause new patient safety concerns and other unintended consequences due to usability issues, disruptions of clinical processes, and unsafe workarounds to circumvent technology-related constraints.2–16”
Quote in the paperSubstantial claim0 of 10 sources checked- cites [2] source
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- Premisecitation
Rapid adoption of electronic health records has revealed potential safety concerns related to EHR design, implementation, and use.
“In particular, rapid adoption of electronic health records (EHRs) has revealed potential safety concerns related to EHR design, implementation, and use.12 17–21”
Quote in the paperSubstantial claim0 of 6 sources checked- cites [12] Institute of Medicine (IOM). Health IT and Patient Safety: Building Safer Systems for Safer Care. Washington, DC: The National Academies Press, 2012.
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- cites [17] source
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- cites [20] Harrington L Kennerly D Johnson C . Safety issues related to the electronic medical record (EMR): synthesis of the literature from the last decade, 2000–2009. J Healthc Manag 2011;56:31–43. source
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- cites [21] Meeks DW Takian A Sittig DF . Exploring the sociotechnical intersection of patient safety and electronic health record implementation. J Am Med Inform Assoc 2014;21(e1) e28 34. source
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- Interpretationown data
EHR-related safety concerns involving both unsafe technology and unsafe use of technology persist long after go-live and despite the sophisticated EHR infrastructure represented in the data source.
“EHR-related safety concerns involving both unsafe technology and unsafe use of technology persist long after ‘go-live’ and despite the sophisticated EHR infrastructure represented in our data source.”
Quote in the paperSubstantial claim - Interpretationreasoning
This example highlights complex interactions between hardware/software, human-computer interface, people, and workflow/communication dimensions, which served to either prevent or obscure users' receipt of appropriate information.
“This example highlights complex interactions between the hardware and software, human–computer interface, people, and workflow and communication dimensions, which served to either prevent or obscure the users’ receipt of appropriate information.”
Quote in the paperNot a substantial claim - Interpretationreasoning
This error occurred due to a number of interacting sociotechnical factors.
“This error occurred due to a number of interacting sociotechnical factors.”
Quote in the paperNot a substantial claim - Premisecitation
Previous studies have largely used isolated event reports without benefit of an independent human factors and informatics investigation to analyze safety concerns in the EHR.
“Previous studies have largely used isolated event reports without benefit of an independent human factors and informatics investigation to analyze safety concerns in the EHR.”
Quote in the paperSubstantial claim0 of 5 sources checked- cites [18] source
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- cites [29] source
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- cites [30] source
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- cites [31] Sparnon E Marella WM . The role of the electronic health record in patient safety events. Harrisburg, PA: Pennsylvania Patient Safety Authority; 2012.
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- cites [55] source
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- Interpretationown data
EHR-related safety concerns have complex sociotechnical origins.
“Because EHR-related safety concerns have complex sociotechnical origins, institutions with long-standing as well as recent EHR implementations should build a robust infrastructure to monitor and learn from them.”
Quote in the paperSubstantial claim - Premisecitation
Previous exploratory studies in patient safety have been able to shed powerful light on contributory factors with a similar sample size.
“Previous exploratory studies in patient safety have been able to shed powerful light on contributory factors with a similar sample size.44”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [44] source
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- Interpretationown data
The study demonstrates the potential utility of analyzing patient safety concerns using a sociotechnical approach to account for the complexities of using EHRs.
“In conclusion, our study demonstrates the potential utility of analyzing patient safety concerns using a sociotechnical approach to account for the complexities of using EHRs.”
Quote in the paperSubstantial claim - Study design and conductreasoning
The study was unable to capture the universe of EHR-related safety concerns that might be occurring.
“Our study was unable to capture the universe of EHR-related safety concerns that might be occurring.”
Quote in the paperNot a substantial claim - Study design and conductcitation
Studies using self-reported data, including this one, are limited by the possibility of reporters' recall bias or knowledge.
“While studies using self-reported data, including this one, are limited by the possibility of reporters’ recall bias or knowledge,56 our methods may allow for a more complete representation of an incident and the underlying safety concern.”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [56] source
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- Study design and conductown data
All incidents were related to use of the same EHR within a single, albeit very large, healthcare system.
“All incidents were related to use of the same EHR within a single, albeit very large, healthcare system.”
Quote in the paperSubstantial claim - Interpretationown data
Having a mature EHR system does not eliminate EHR-related safety concerns.
“Having a mature EHR system clearly does not eliminate EHR-related safety concerns, and a majority of reported incidents were phase 1 or unsafe technology.”
Quote in the paperSubstantial claim - Interpretationown data
The four categories that emerged from the analysis appear to represent significant safety concerns that need to be addressed with current and future EHR implementations.
“The four categories that emerged from our analysis appear to represent significant safety concerns that need to be addressed with current and future EHR implementations.”
Quote in the paperNot a substantial claim
- May combine two claims. 26
- Classified as probably not a substantial claim. 20
May combine two claims.
Findingown dataFour broad types of safety concerns were prominent: unmet data display needs within the EHR; problems with software modifications or upgrades; concerns related to system-system interfaces; and hidden dependencies within the EHR.
“Although the reports documented a variety of EHR-related safety incidents, four broad types of safety concerns were prominent: unmet data display needs within the EHR; problems with software modifications or upgrades; concerns related to system–system interfaces; and hidden dependencies within the EHR.”
Quote in the paperSubstantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
FindingreasoningSince the printers were installed and configured before recruitment of the current staff, the configuration error was not immediately recognized.
“Since these printers were installed and configured before recruitment of the current staff, the configuration error was not immediately recognized.”
Quote in the paperNot a substantial claimMay combine two claims.
FindingcitationAnother concern involved legacy software that needed an upgrade or maintenance, but support staff did not have sufficient knowledge of these systems.
“Another concern involved ‘legacy’ software (ie, an older system that has not evolved despite newer technologies50) that needed an upgrade or maintenance, but support staff did not have sufficient knowledge of these systems.”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [50] Brodie ML Stonebraker M . Migrating legacy systems: gateways, interfaces & the incremental approach. Morgan Kaufmann Publishers Inc., 1995.
Not checked in the free run.
Probably not a substantial claim: may not pass S3 (load-bearing).
Findingown dataThe selected incidents were reported from 55 unique VA facilities.
“The selected incidents were reported from 55 unique VA facilities.”
Quote in the paperNot a substantial claimMay combine two claims.
Findingown dataFour types of safety concerns emerged: unmet display needs, software modifications or upgrades, data transmission at system-system interfaces, and hidden dependencies in distributed systems.
“We classified these concerns into four types: unmet display needs in the EHR, safety concerns with software modifications or upgrades, concerns related to data transmission at system–system interfaces, and concerns of ‘hidden dependencies’ in distributed systems (ie, when one EHR component unexpectedly or unknowingly is affected by the state or condition of another).”
Quote in the paperSubstantial claimMay combine two claims.
Findingown dataIncidents frequently reflected more than one sociotechnical dimension: 40 incidents had two dimensions, 23 had three, and seven had four.
“A majority (70%) involved two or more model dimensions.”
- Also stated in: § Results · plain
“Incidents frequently reflected occurrence of more than one sociotechnical dimension: 40 incidents were classified with two sociotechnical dimensions, 23 incidents had three, and seven involved four dimensions.”
Quote in the paperSubstantial claim- Also stated in: § Results · plain
May combine two claims.
Findingown dataIncidents in the hidden dependencies category were largely dependent on multiple interactions between these dimensions, and only one incident was coded with a single dimension.
“Incidents in this category were also noted to be largely dependent on multiple interactions between these dimensions, and only one incident was coded with a single dimension.”
Quote in the paperNot a substantial claimMay combine two claims.
Findingown dataPatient context-related concerns were caused by network failures, conflicts created by non-EHR software, and EHR upgrades that were not compliant with context protocols.
“Patient context-related concerns were caused by network failures, conflicts created by non-EHR software, and EHR upgrades that were not compliant with context protocols.”
Quote in the paperNot a substantial claimMay combine two claims.
Findingown dataThe software modification concern type was most often associated with phase 1 (21 incidents); three were phase 2, and none were phase 3.
“This concern type was most often associated with phase 1 EHR safety (21 incidents). Three concerns were classified as phase 2, and none were phase 3.”
Quote in the paperNot a substantial claimMay combine two claims.
Findingown dataSystem-system interface concerns involved interactions from multiple sociotechnical dimensions: hardware and software (17 incidents), workflow (6 incidents), and content (5 incidents).
“As highlighted in this example, the system–system interface concern involved interactions from multiple sociotechnical dimensions: hardware and software (17 incidents), workflow (6 incidents), and content (5 incidents).”
Quote in the paperNot a substantial claimMay combine two claims.
Findingown dataThe concerns of hidden dependencies primarily involved the dimensions of hardware and software (14 of 17 incidents), workflow (14 incidents), clinical content (9 incidents), and people (5 incidents).
“The concerns of hidden dependencies primarily involved the dimensions of hardware and software (14 of 17 incidents), workflow (14 incidents), clinical content (9 incidents), and people (5 incidents).”
Quote in the paperNot a substantial claimMay combine two claims.
Findingnone givenA dose error warning appeared on order entry, and this particular warning was known to have a high false positive rate.
“Although a dose error warning appeared on order entry, this particular warning was known to have a high false positive rate.”
Quote in the paperNot a substantial claimMay combine two claims.
Findingown dataOn IPS-assessed safety scores, 48 investigations were scored low, 38 intermediate, and 14 high.
“On the IPS-assessed safety scores, 48 investigations were scored low, 38 intermediate, and 14 were scored high.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
FindingreasoningThe nurse, unaware of the discrepancy between the prescribed amount and the amount approved by the pharmacist, administered the larger dose.
“The nurse, unaware of the discrepancy between the prescribed amount and the amount approved by the pharmacist, administered the larger dose.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
PremisecitationThe authors previously developed a sociotechnical model that proposes eight interdependent dimensions essential to understand EHR-related safety.
“For instance, we previously developed a sociotechnical model that proposes eight interdependent dimensions that are essential to understand EHR-related safety (table 1; Sittig and Singh model).24 34”
Quote in the paperNot a substantial claim0 of 2 sources checkedClassified as probably not a substantial claim.
PremisecitationThe sociotechnical model accounts for complexities of technology, users, workflow, and larger external or organizational policies and context in assessment of EHR-related safety concerns.
“The model accounts for the complexities of technology, its users, the involved workflow, and the larger external or organizational policies and context in assessment of EHR-related safety concerns.35 36”
Quote in the paperSubstantial claim0 of 2 sources checkedProbably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
PremisecitationInvestments in health information technology can enhance the safety and efficiency of patient care and enable knowledge discovery.
“Investments in health information technology (HIT) can enhance the safety and efficiency of patient care and enable knowledge discovery.1”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [1] Institute of Medicine (IOM). Crossing the quality chasm a new health system for the 21st century. The National Academy Press, 2001.
Not checked in the free run.
Probably not a substantial claim: may not pass S3 (load-bearing).
Study design and conductown dataMembers of the multidisciplinary project team provided guidance on the content of the themes.
“Members of our multidisciplinary project team, whose areas of expertise included clinical medicine, patient safety, informatics, human factors, and information technology, provided guidance on the content of the themes.”
Quote in the paperNot a substantial claimMay combine two claims.
InterpretationreasoningAs compared with system-system interfaces, hidden dependencies are unknown, and therefore potential points of failure and possible safety concerns may not be readily identified.
“As compared with system–system interfaces, hidden dependencies are unknown, and therefore potential points of failure and possible safety concerns may not be readily identified.”
Quote in the paperSubstantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
InterpretationreasoningThis example demonstrates how a complex interaction of a technical dimension with non-technical dimensions can potentially develop into a safety concern.
“This example demonstrates how a complex interaction of a technical dimension with non-technical dimensions can potentially develop into a safety concern.”
Quote in the paperNot a substantial claimMay combine two claims.
InterpretationreasoningAs a result of the poor fit, displayed information available to the end user failed to reduce uncertainty or led to increased potential for patient harm.
“As a result of this poor fit, the displayed information available to the end user failed to reduce uncertainty or led to increased potential for patient harm.”
Quote in the paperSubstantial claimClassified as probably not a substantial claim. May combine two claims.
Study design and conductreasoningGiven the rich nature of the qualitative data, 100 investigations was believed to be both valuable and feasible.
“Given the rich nature of the qualitative data, we believed this number was both valuable and feasible.”
Quote in the paperSubstantial claimClassified as probably not a substantial claim. May combine two claims.
Study design and conductreasoningThe authors do not report inter-rater reliability because the aim was to describe the nature and context of common EHR-related safety concerns, not solely classification according to the sociotechnical models.
“We do not report inter-rater reliability because the aim of the study was to describe the nature and context of common EHR-related safety concerns, not solely classification according to the sociotechnical models.47 49”
Quote in the paperSubstantial claim0 of 2 sources checkedClassified as probably not a substantial claim.
InterpretationreasoningA completed investigation provides additional contextual details pertinent to the incident under study compared with traditional event reports.
“Thus, a completed investigation provides additional contextual details pertinent to the incident under study as compared with traditional event reports.”
Quote in the paperSubstantial claimProbably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
Study design and conductown dataTwo coding authors independently indexed each safety concern after reviewing the IPS investigation results, and discrepancies in coding were resolved by consensus.
“The two coding authors (ie, a physician with informatics training and a human factors engineer) independently indexed each safety concern after reviewing the results of the IPS investigation. Discrepancies in coding were then resolved by consensus.”
Quote in the paperNot a substantial claimMay combine two claims.
PremisecitationKnown safety concerns related to erroneous editing or merging of patient records resulting in comingled or overlaid records were excluded because they are not routinely analyzed by IPS and are handled primarily by a separate office in the VA.
“Although these are known safety concerns,43 they were excluded because they are not routinely analyzed by IPS and are handled primarily by a separate office in the VA.”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [43] source
Not checked in the free run.
Probably not a substantial claim: may not pass S3 (load-bearing).
Study design and conductown dataTwo authors independently reviewed and summarized the investigation reports to become familiar with the data.
“First, two authors (DWM and MWS) independently reviewed and summarized the investigation reports to become familiar with the data, but at this secondary stage of analysis, we made no further effort to replicate the safety concern or investigation, determine additional causes, or offer additional solutions.”
Quote in the paperNot a substantial claimMay combine two claims.
InterpretationreasoningDespite capturing a low percentage of errors, the authors were able to gain insight about non-technical aspects of EHR-related safety concerns that may not be routinely considered in technology-focused investigations.
“Despite capturing a low percentage of errors, we were able to gain insight about non-technical aspects of EHR-related safety concerns that may not be routinely considered in technology-focused investigations.”
Quote in the paperSubstantial claimMay combine two claims.
Study design and conductreasoningThe findings may not represent all types of EHR-related safety concerns and might not be generalizable to other institutions with different organizational characteristics, EHR infrastructure, or patient safety reporting mechanisms.
“Nevertheless, our findings may not represent all types of EHR-related safety concerns and might not be generalizable to other institutions with different organizational characteristics, EHR infrastructure, or patient safety reporting mechanisms.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S2 (checkable).
InterpretationreasoningThe findings underscore the importance of continuing the process of detecting and addressing safety concerns long after EHR implementation and 'go-live' has occurred.
“Our findings underscore the importance of continuing the process of detecting and addressing safety concerns long after EHR implementation and ‘go-live’ has occurred.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
Study design and conductnone givenThe circumstances or implications of unsafe conditions or near misses may be different from adverse events that result in patient harm.
“Although the analysis of unsafe conditions or near misses is useful to illustrate concerns in EHR-enabled care, we acknowledge that their circumstances or implications may be different from adverse events that result in patient harm.”
Quote in the paperNot a substantial claimMay combine two claims.
PremisecitationIn general, fewer than 10% of medical errors are captured through reporting, and such data do not allow calculation of prevalence rates.
“In general, fewer than 10% of medical errors are captured through reporting, and such data do not allow us to calculate prevalence rates.56 59 60”
Quote in the paperNot a substantial claim0 of 3 sources checked- cites [56] source
Not checked in the free run.
- cites [59] Sari AB-A Trevor AS Alison C . Sensitivity of routine system for reporting patient safety incidents in an NHS hospital: retrospective patient case note review. BMJ 2007;334. source
Not checked in the free run.
- cites [60] source
Not checked in the free run.
Probably not a substantial claim: may not pass S3 (load-bearing).
Study design and conductown dataThe data used for the analysis were composed of safety concerns that ranged from unsafe conditions to patient harm.
“The data used for our analysis were composed of safety concerns that ranged from unsafe conditions to patient harm.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
Study design and conductown dataThe authors did not analyze additional data on patient outcomes as a result of these concerns.
“All four emergent safety concerns affected, or had the potential to affect, multiple patients, but we did not analyze additional data on patient outcomes as a result of these concerns.”
Quote in the paperNot a substantial claimMay combine two claims.
Study design and conductcitationAdditional strengths of the study include the nationwide distribution of the sample of EHR-related safety incidents and the relatively sophisticated implementation and use of the EHR across the VA healthcare system.
“Additional strengths of our study include the nationwide distribution of our sample of EHR-related safety incidents and the relatively sophisticated implementation and use of the EHR across the VA healthcare system.39”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [39] Spetz J Burgess JF Phibbs CS . What determines successful implementation of inpatient information technology systems? Am J Manag Care 2012;18:157–62.
Not checked in the free run.
Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
PremisecitationAs an early adopter of EHRs, the VA has evolved into a 'learning system' that dedicates resources to investigating safety concerns and making EHR-related safety improvements decades after first launch.
“As an early adopter of EHRs, the VA has evolved into a ‘learning system’ that dedicates resources to investigating safety concerns and making EHR-related safety improvements decades after first launch.42”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [42] Taylor L Wood SD Chapman R . Analysis and Mitigation of Reported Informatics Patient Safety Adverse Events at the Veterans Health Administration. Human Factors and Ergonomics Society, 2012. source
Not checked in the free run.
May combine two claims.
Study design and conductown dataThe case descriptions were rich (2-4 single-spaced pages), spanned a period of 3 years, and represented a continuum of care from home-based primary care to large, urban medical centers.
“Although the sample size is smaller than that of some other studies, the case descriptions were rich (ie, 2–4 single-spaced pages), spanned a period of 3 years, and represented a continuum of care from home-based primary care to large, urban medical centers.”
Quote in the paperSubstantial claimClassified as probably not a substantial claim. May combine two claims.
InterpretationreasoningTechnology-based solutions alone will only partially mitigate EHR-related safety concerns, and interventions to improve EHR-related safety should encompass the people, organizations, systems, and policies that influence how EHRs are used.
“Our study suggests that technology-based solutions alone will only partially mitigate concerns and that interventions to improve EHR-related safety should encompass the people, organizations, systems, and policies that influence how EHRs are used.”
Quote in the paperSubstantial claimClassified as probably not a substantial claim. May combine two claims.
InterpretationreasoningSafety concerns identified had complex sociotechnical origins and would need multifaceted strategies for improvement.
“Safety concerns we identified had complex sociotechnical origins and would need multifaceted strategies for improvement.”
Quote in the paperSubstantial claim
The paper relies on this without support.
Currently, few healthcare institutions have reporting and analysis capabilities similar to the VA.
“Currently, few healthcare institutions have reporting and analysis capabilities similar to the VA.”
The paper relies on this without support.
Few healthcare systems have robust reporting and analytic infrastructure similar to the VA's Informatics Patient Safety Office.
“However, few healthcare systems have robust reporting and analytic infrastructure similar to the VA's IPS.”
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
This study has also added to an emerging but limited UK evidence base that has reported potential negative impacts of electronic records on the doctor-patient relationship and patient safety in secondary care.
“This study has also added to an emerging but limited UK evidence base that has reported potential negative impacts of electronic records on the doctor-patient relationship [35] and patient safety in secondary care [36–38].”
From Exploring the implementation of an electronic record into a maternity unit: a qualitative study using Normalisation Process Theory (2017) · cites this paper as [36]
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Self-citation
Flagged first, then by citations
Research works printed but not linked: 1
- Institute of Medicine (IOM). Health IT and Patient Safety: Building Safer Systems for Safer Care. Washington, DC: The National Academies Press, 2012.
Cited by
Sorted by citations
Electronic Health Records: Then, Now, and in the Future
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“Mounting pressure will require EHR implementations to build a robust infrastructure to monitor and learn from adverse events, errors, and potential adverse events and errors [204].”
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“System configuration issues were also linked to software updates, eg, decision support errors following updates to a drug database.(26) Sociotechnical contextual variables that contributed to information errors were identified in 71% of studies (n1⁄424).”
BackgroundReport of the AMIA EHR-2020 Task Force on the status and future direction of EHRs
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Current challenges in health information technology–related patient safety
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“55 This must change if we are to gather enough data to identify common modes of failure and estimate the likelihood of similar future events.”
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“This reporting guideline, which we call the Safety-related EHR Research (SAFER) Reporting Framework, can help guide successful implementation (19–25), has been used to understand the dynamic nature of relationships between health IT (including computerized provider order entry, clinical decision…”
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“However, the clinical use of digital information for diagnostic, therapeutic, and prognostic purposes has multiple patient safety problems, including significant harms and death, some of which result from poor information quality (IQ) [6-9].”
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Kim, Y., Jung, K., Park, Y., Shin, D., Cho, S. Y., Yoon, D., & Park, R. W. (2017) · International Journal of Medical Informatics · doi:10.1016/j.ijmedinf.2017.02.009 · Cited by 63 · see citing works
Ten key considerations for the successful optimization of large-scale health information technology
Cresswell, K. M., Bates, D. W., & Sheikh, A. (2016) · Journal of the American Medical Informatics Association · doi:10.1093/jamia/ocw037 · Cited by 67 · see citing works
“In relation to technical aspects, for instance, continued measurement and monitoring of technical functioning, including system reliability, response time, upgrades, and system-induced errors, can help in anticipating and mitigating risks.(47,48) Some useful guidance in this respect can be found in a recent conceptual…”
BackgroundCresswell, K. M., Lee, L., Mozaffar, H., Williams, R., Sheikh, A., & on behalf of the NIHR ePrescribing Programme Team (2017) · Health Services Research · doi:10.1111/1475-6773.12581 · Cited by 64 · see citing works
“health system concluded that “EHR-related safety concerns involving both unsafe technology and unsafe use of technology persist long after ‘go-live’” (Meeks et al. 2014).”
BackgroundRobotics Technology in Mental Health Care
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“This has been a growing problem in treatment and safety across other healthcare disciplines, and there is all the more reason to suspect this problem would be magnified for a profession centered on face-to-face interaction (cf. Levinson, Gorawara-Bhat, & Lamb, 2012; Meeks et al., 2014; Montague & Asan, 2014).”
BackgroundLippke, S., Wienert, J., Keller, F. M., Derksen, C., Welp, A., Kötting, L., Hofreuter-Gätgens, K., Müller, H., Louwen, F., Weigand, M., et al. (2019) · BMC Health Services Research · doi:10.1186/s12913-019-4579-y · Cited by 67 · see citing works
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“The third study, by Meeks et al. (2015), analyzed incidents tracked by a non-punitive, voluntary reporting system used at the U.S. Veterans Health Administration [122].”
Toward Designing Information Display to Support Critical Care
Dunbar, S., Macpherson, B. C., Moretti, E., Fiol, G. D., Bolte, J., Taekman, J. M., Segall, N., & Wright, M. C. (2016) · Applied Clinical Informatics · doi:10.4338/aci-2016-03-ra-0033 · Cited by 56 · see citing works
“Inefficiencies and the opportunity to miss key information make electronic health care information presentation a crucial patient safety priority [8].”
BackgroundDigital technologies: An exploratory study of their role in the resilience of healthcare services
da Rosa, V. M., Saurin, T. A., Tortorella, G. L., Fogliatto, F. S., Tonetto, L. M., & Samson, D. A. (2021) · Applied Ergonomics · doi:10.1016/j.apergo.2021.103517 · Cited by 65 · see citing works
Salahuddin, L. B., & Ismail, Z. (2015) · International Journal of Medical Informatics · doi:10.1016/j.ijmedinf.2015.07.004 · Cited by 66 · see citing works
“nadequate knowledge of the health IT by technical support staff an potentially develop safety risks [89].”
BackgroundInfluentialDunn Lopez, K., Chin, C.-L., Leitão Azevedo, R. F., Kaushik, V., Roy, B., Schuh, W., Banks, K., Sousa, V., & Morrow, D. (2021) · Applied Ergonomics · doi:10.1016/j.apergo.2021.103359 · Cited by 62 · see citing works
Electronic Health Records and Improved Patient Care: Opportunities for Applied Psychology
Ratwani, R. M. (2017) · Current Directions in Psychological Science · doi:10.1177/0963721417700691 · Cited by 70 · see citing works
“The poor design of EHRs is largely recognized as a major source of these challenges (Meeks et al., 2014; Zahabi, Kaber, & Swangnetr, 2015).”
BackgroundDalal, A. K., Fuller, T. E., Garabedian, P., Ergai, A., Balint, C., Bates, D. W., & Benneyan, J. C. (2019) · Journal of the American Medical Informatics Association · doi:10.1093/jamia/ocz002 · Cited by 58 · see citing works
The biopsychosociotechnical model: a systems-based framework for human-centered health improvement
Card, A. J. (2022) · Health Systems · doi:10.1080/20476965.2022.2029584 · Cited by 66 · see citing works
“…access to doctors’ clinical notes may improve patients’ understanding, adherence, and self-care (Walker et al., 2015) Although they were adopted in part to improve safety, EHRs can also contribute to patient harm (P Carayon et al., 2017; Graber et al., 2019; Meeks et al., 2014; Menon et al., 2014)”
BackgroundSafety huddles to proactively identify and address electronic health record safety
Menon, S., Singh, H., Giardina, T. D., Rayburn, W. L., Davis, B. P., Russo, E. M., & Sittig, D. F. (2016) · Journal of the American Medical Informatics Association · doi:10.1093/jamia/ocw153 · Cited by 48 · see citing works
Self-citationWright, M. C., Borbolla, D. A., Waller, R. G., Fiol, G. D., Reese, T., Nesbitt, P., & Segall, N. (2019) · Journal of Biomedical Informatics · doi:10.1016/j.yjbinx.2019.100041 · Cited by 48 · see citing works
“However, the ability of information displays to support these activities has been criticized [3–5], and their use has been linked with errors that compromise patient safety [6,7].”
BackgroundMartin, G., Ghafur, S., Cingolani, I., Symons, J., King, D., Arora, S., & Darzi, A. W. (2019) · The Lancet Digital Health · doi:10.1016/s2589-7500(19)30057-3 · Cited by 49 · see citing works
Rahman Jabin, M. S., Steen, M., Wepa, D., & Bergman, P. (2023) · DIGITAL HEALTH · doi:10.1177/20552076231174307 · Cited by 44 · see citing works
Scantlebury, A., Sheard, L., Watt, I., Cairns, P., Wright, J., & Adamson, J. (2017) · BMC Medical Informatics and Decision Making · doi:10.1186/s12911-016-0406-0 · Cited by 41 · see citing works
Evidence-based Health Informatics: How Do We Know What We Know?
Ammenwerth, E. (2015) · Methods of Information in Medicine · doi:10.3414/me14-01-0119 · Cited by 45 · see citing works
“Best practice examples are already available [83].”
Automation to optimise physician treatment of individual patients: examples in psychiatry
Bauer, M., Monteith, S., Geddes, J., Gitlin, M. J., Grof, P., Whybrow, P. C., & Glenn, T. (2019) · The Lancet Psychiatry · doi:10.1016/s2215-0366(19)30041-0 · Cited by 44 · see citing works
Barnett, M. L., Mehrotra, A., & Jena, A. B. (2016) · BMJ · doi:10.1136/bmj.i3835 · Cited by 44 · see citing works
Building a learning health system using clinical registers: a non-technical introduction
Øvretveit, J., Nelson, E. C., & James, B. C. (2016) · Journal of Health Organization and Management · doi:10.1108/jhom-06-2016-0110 · Cited by 42 · see citing works
Rahman Jabin, M. S., & Pan, D. (2023) · DIGITAL HEALTH · doi:10.1177/20552076231203600 · Cited by 41 · see citing works
“Six incidents were identi fi ed under this theme (IR 2,5,6,17,18,22 ).”
BackgroundJabin, M. S. R. (2024) · Frontiers in Digital Health · doi:10.3389/fdgth.2024.1367431 · Cited by 43 · see citing works
Unintended adverse consequences of a clinical decision support system: two cases
Stone, E. G. (2017) · Journal of the American Medical Informatics Association · doi:10.1093/jamia/ocx096 · Cited by 39 · see citing works
“There have been concerns voiced in the past about the unintended adverse consequences (UACs) of aspects of health IT, including computerized physician order entry (CPOE) and electronic health records (EHRs).(30) Studies have also been published specifically addressing UACs in CDSSs.”
BackgroundOncologists’ Views Regarding the Role of Electronic Health Records in Care Coordination
Asan, O., Nattinger, A. B., Gürses, A. P., Tyszka, J. T., & Yen, T. W. F. (2018) · JCO Clinical Cancer Informatics · doi:10.1200/cci.17.00118 · Cited by 38 · see citing works
Nurse workarounds in the electronic health record: An integrative review
Fraczkowski, D., Matson, J., & Lopez, K. D. (2020) · Journal of the American Medical Informatics Association · doi:10.1093/jamia/ocaa050 · Cited by 40 · see citing works
“Usability, defined by Nielsen to include the 5 attributes of (1) easy to learn and (2) remember, (3) efficient to use, (4) has few errors, and (5) is subjectively pleasing,(73) has emerged as a critical problem in health care that increases chance of errors across an array of health information technologies.(18,74,75)…”
BackgroundUnintended Consequences of EHR Systems: A Narrative Review
Vanderhook, S., & Abraham, J. (2017) · Proceedings of the International Symposium on Human Factors and Ergonomics in Health Care · doi:10.1177/2327857917061048 · Cited by 37 · see citing works
“Meeks et al. (2014) noted when a sociotechnical dimension was involved in a safety incident, there was an interaction by another dimension.”
BackgroundInfluentialScott, I. A., Sullivan, C. M., & Staib, A. N. (2018) · Australian Health Review · doi:10.1071/ah17153 · Cited by 39 · see citing works
Barrett, A. K., & Stephens, K. K. (2016) · Health Communication · doi:10.1080/10410236.2016.1196422 · Cited by 35 · see citing works
“These front-line implementers of EHR systems are being studied in medical, nursing, and medical information technology journals (e.g., Ford, Menachemi, Peterson, & Huerta, 2009; Goh, Gao, & Agarwal, 2011; Meeks et al., 2014; Menachemi & Collum, 2011; Noyes, Lewis, Bennett, Widdas, & Brombley, 2013; Stutzer & Rushton,…”
BackgroundInfluentialRahman Jabin, M. S., & Hammar, T. (2022) · DIGITAL HEALTH · doi:10.1177/20552076221131139 · Cited by 32 · see citing works
“46 If these challenges are left undetected even for a shorter period, it can cause severe consequences for multiple patients and widespread impact at a system level.”
BackgroundWright, A. T., Ash, J. S., Aaron, S., Ai, A., Hickman, T.-T. T., Wiesen, J. F., Galanter, W., McCoy, A. B., Schreiber, R., Longhurst, C., et al. (2018) · International Journal of Medical Informatics · doi:10.1016/j.ijmedinf.2018.08.001 · Cited by 31 · see citing works
“It has also been effective in informatics research [47, 48].”
Self-citationPowell, L., Sittig, D. F., Chrouser, K. L., & Singh, H. (2020) · JAMA Network Open · doi:10.1001/jamanetworkopen.2020.6752 · Cited by 34 · see citing works
Self-citationTurner, P. A., Kushniruk, A. W., & Nøhr, C. G. (2017) · Yearbook of Medical Informatics · doi:10.15265/iy-2017-014 · Cited by 28 · see citing works
“…implementation, and evaluation of these systems, we have long understood that most challenges result from a failure to design for the complexity of socio-technical systems in healthcare and/or a failure to understand and engage end-users in technology adoption and use in context [11, 12, 13].”
BackgroundWang, J., Liang, H., Kang, H., & Gong, Y. (2019) · Applied Clinical Informatics · doi:10.1055/s-0039-1678693 · Cited by 35 · see citing works
“25 Guided by the sociotechnical model, a composite classi fi cation of health ITrelated contributing factors was created and further used to investigate the health IT related sentinel events reported to the Joint Commission.”
MethodInterfacing With the Electronic Health Record (EHR): A Comparative Review of Modes of Documentation
Avendano, J. P., Gallagher, D. O., Hawes, J., Boyle, J. J., Glasser, L., Aryee, J. N. A., & Katt, B. M. (2022) · Cureus · doi:10.7759/cureus.26330 · Cited by 31 · see citing works
“While EHRs in their current form may improve the quality of clinical documentation, they frequently result in increased documentation times, decreased clinician satisfaction, decreased length of patient interaction, new sources of risk to patient safety, and substantial investment costs for providers [4,22,23].”
BackgroundEHR-BERT: A BERT-based model for effective anomaly detection in electronic health records
Niu, H., Omitaomu, O. A., Langston, M. A., Olama, M., Özmen, Ö., Klasky, H. B., Laurio, A., Ward, M. C., & Nebeker, J. R. (2024) · Journal of Biomedical Informatics · doi:10.1016/j.jbi.2024.104605 · Cited by 37 · see citing works
Wright, A. T., Aaron, S., & Sittig, D. F. (2016) · Journal of the American Medical Informatics Association · doi:10.1093/jamia/ocw039 · Cited by 28 · see citing works
Self-citationManagement of Open Innovation in Healthcare for Cost Accounting Using EHR
Biancone, P., Secinaro, S. F., Brescia, V., & Calandra, D. (2019) · Journal of Open Innovation Technology Market and Complexity · doi:10.3390/joitmc5040099 · Cited by 30 · see citing works
The impact of electronic records on patient safety: a qualitative study
Scantlebury, A., Adamson, J., Watt, I. S., Sheard, L., Cairns, P. A., & Wright, J. (2016) · BMC Medical Informatics and Decision Making · doi:10.1186/s12911-016-0299-y · Cited by 28 · see citing works
“S evidence base, which has identified human errors and technical issues associated with Health Information Technology [8–12, 27–33] and which have the potential to increase the risks for patient safety.”
BackgroundScheitel, M. R., Kessler, M., Shellum, J. L., Peters, S. G., Milliner, D. S., Liu, H., Elayavilli, R. K., Poterack, K. A., Miksch, T. A., Boysen, J. J., et al. (2017) · Applied Clinical Informatics · doi:10.4338/aci-2016-07-ra-0114 · Cited by 28 · see citing works
Patient safety goals for the proposed Federal Health Information Technology Safety Center
Sittig, D. F., Classen, D. C., & Singh, H. (2014) · Journal of the American Medical Informatics Association · doi:10.1136/amiajnl-2014-002988 · Cited by 28 · see citing works
“For example, ONC could partner with not for profit entities (eg, ECRI’s recently formed ‘Partnership for promoting HIT patient safety’(18)) to create a federally funded research and development center for event reporting, analysis, and information sharing, similar in concept to the Veterans Affairs’ Informatics Patien…”
BackgroundSelf-citationSavoy, A., Militello, L. G., Patel, H., Flanagan, M., Russ, A. L., Daggy, J., Weiner, M., & Saleem, J. J. (2018) · Journal of Biomedical Informatics · doi:10.1016/j.jbi.2018.07.021 · Cited by 27 · see citing works
Ferreira, A. M. D., de Oliveira, J. L. C., Camillo, N. R. S., et al. (2019) · Revista gaúcha de enfermagem · doi:10.1590/1983-1447.2019.20180140 · Cited by 25 · see citing works
Human-Computer Interaction, Ethics, and Biomedical Informatics
Hochheiser, H., & Valdez, R. S. (2020) · Yearbook of Medical Informatics · doi:10.1055/s-0040-1701990 · Cited by 24 · see citing works
“Consistent with earlier efforts [6-9], examinations of patient safety reports continue to find evidence of a strong impact of usability problems on EHR safety [10, 11].”
ResultRatwani, R. M., Hettinger, A. Z., Kosydar, A., Fairbanks, R. J. T., & Hodgkins, M. L. (2016) · Journal of the American Medical Informatics Association · doi:10.1093/jamia/ocw092 · Cited by 24 · see citing works
“Many EHRs are not prospectively designed, developed, and implemented to support the cognitive needs of clinicians, resulting in stress, frustration, reduced efficiency, and patient safety hazards.(4,5) In an effort to promote EHR usability, the Office of the National Coordinator for Health Information Technology (ONC)…”
BackgroundElectronic Health Records as an Educational Tool: Viewpoint
Habboush, Y. Y., Hoyt, R., & Beidas, S. (2018) · JMIR Medical Education · doi:10.2196/10306 · Cited by 22 · see citing works
“Other interpersonal and communication skills benefits from the huddle include promoting team dynamics and interdisciplinary work [20].”
Backgroundde Vreede, M. A. V., McGrath, A., & de Clifford, J. (2018) · Australian Health Review · doi:10.1071/ah17119 · Cited by 23 · see citing works
Health Information Technology Acceptance Framework for diabetes management
Ayanlade, O. S., Oyebisi, T. O., & Kolawole, B. A. (2019) · Heliyon · doi:10.1016/j.heliyon.2019.e01735 · Cited by 23 · see citing works
“That is, no matter be the usefulness of the technology, if it is not easy to understand and easy to interact with, then its usefulness is useless as con fi rmed by Meeks et al. (2014), as this will determine the HIT acceptance and sustainability among staff.”
BackgroundResultBednorz, A., Mak, J. K. L., Jylhävä, J., & Religa, D. (2023) · Clinical Interventions in Aging · doi:10.2147/cia.s400887 · Cited by 27 · see citing works
Kemp, T., Ayton, J. E., Butler-Henderson, K. A., & Lam, M. K. (2024) · Social Theory & Health · doi:10.1057/s41285-024-00214-5 · Cited by 37 · see citing works
“Meeks et al. reported that electronic health records have complex sociotechnical origins which require organisations to monitor and learn from system implementations and build robust infrastructure [27].”
Horsky, J., & Ramelson, H. Z. (2016) · Journal of Biomedical Informatics · doi:10.1016/j.jbi.2016.10.004 · Cited by 21 · see citing works
Engaging the disability community in informatics research: rationales and practical steps
Valdez, R. S., Lyon, S. E., Wellbeloved-Stone, C. A., Collins, M., Rogers, C. C., Cantin-Garside, K. D., Fortes, D., Kim, C., Desai, S. S., Keim‐Malpass, J., et al. (2022) · Journal of the American Medical Informatics Association · doi:10.1093/jamia/ocac136 · Cited by 25 · see citing works
Clinical Information Systems – From Yesterday to Tomorrow
Gardner, R. M. (2016) · Yearbook of Medical Informatics · doi:10.15265/iys-2016-s010 · Cited by 22 · see citing works
“In addition, the treatment strategies of the medical profession are not completely interchangeable with each patient’s condition and are not performed without error [99, 100, 107-115].”
BackgroundEthics, Medicine, and Information Technology
Goodman, K. W. (2015) · Cambridge University Press eBooks · doi:10.1017/cbo9781139600330 · Cited by 40 · see citing works
Ahlness, E. A., Orlander, J. D., Brunner, J., Cutrona, S. L., Kim, B., Molloy-Paolillo, B. K., Rinne, S. T., Rucci, J. M., Sayre, G. G., & Anderson, E. (2023) · Journal of General Internal Medicine · doi:10.1007/s11606-023-08282-5 · Cited by 21 · see citing works
“20 Furthermore, the emotional effects of disrupted work can impact employee confidence and morale, leading to burnout and turnover.”
BackgroundAmosa, T. I., Izhar, L. I., Sebastian, P., Ismail, I. B., Ibrahim, O., & Ayinla, S. L. (2023) · IEEE Access · doi:10.1109/access.2023.3284682 · Cited by 22 · see citing works
“To address the challenges of EHR-related patient safety, comprehensive and more recent ‘‘socio-technical’’ methods that account for these components are required [69], [70], [71].”
BackgroundMethodAdvocating for Greater Usability in Clinical Technologies
Lopez, K. D., & Fahey, L. J. (2018) · Critical Care Nursing Clinics of North America · doi:10.1016/j.cnc.2018.02.007 · Cited by 16 · see citing works
Nursing Student Experiences Regarding Safe Use of Electronic Health Records
Whitt, K. J., Eden, L. M., Merrill, K. C., et al. (2016) · CIN Computers Informatics Nursing · doi:10.1097/cin.0000000000000291 · Cited by 17 · see citing works
Kang, H., Wang, J., Yao, B., Zhou, S., & Gong, Y. (2018) · JAMIA Open · doi:10.1093/jamiaopen/ooy042 · Cited by 16 · see citing works
Martin, G., Arora, S., Shah, N., King, D., & Darzi, A. W. (2019) · Health Informatics Journal · doi:10.1177/1460458219854602 · Cited by 15 · see citing works
Khairat, S. S., Coleman, C., Teal, R., et al. (2021) · Health Informatics Journal · doi:10.1177/1460458221997914 · Cited by 14 · see citing works
Bae, J., Rask, K. J., & Becker, E. R. (2017) · American Journal of Medical Quality · doi:10.1177/1062860617702453 · Cited by 17 · see citing works
“Furthermore, it is not uncommon to find evidence that EMRs may lead to unintended consequences such as fostering new, unique safety risks and increasing the incidence of adverse patient safety events and medical errors.(24-26) The potential benefits accruing to an EMR investment are dependent in part on how well the v…”
BackgroundSafe use of hospital information systems: an evaluation model based on a sociotechnical perspective
Salahuddin, L. B., Ismail, Z., Ikram, R. R. R., Hashim, U. R., Idris, A., Ismail, N. H., Hassan, N. H., & Rahim, F. A. (2019) · Behaviour and Information Technology · doi:10.1080/0144929x.2019.1597164 · Cited by 14 · see citing works
“The root cause of HIS-related errors are complex, and originate from various technical and/or sociotechnical factors (Meeks et al. 2014; Vanderhook and Abraham 2017).”
BackgroundApplying requisite imagination to safeguard electronic health record transitions
Sittig, D. F., Lakhani, P., & Singh, H. (2021) · Journal of the American Medical Informatics Association · doi:10.1093/jamia/ocab291 · Cited by 16 · see citing works
Self-citationBramo, S. S., Desta, A., & Syedda, M. (2022) · Digital Health · doi:10.1177/20552076221131144 · Cited by 18 · see citing works
“Consistently, studies conducted by 30,48 – 50 demonstrated simplicity to navigate and ease of access, clarity, and ef fi ciency as a factor associated with technology acceptance and use.”
BackgroundAssessing the Status Quo of EHR Accessibility, Usability, and Knowledge Dissemination
Khairat, S., Coleman, C., Russomagno, S., & Gotz, D. (2018) · eGEMs (Generating Evidence & Methods to improve patient outcomes) · doi:10.5334/egems.228 · Cited by 16 · see citing works
“More recently, safety concerns have been linked to EHRs in particular, specifically as they relate to workflow and data display [14].”
BackgroundLaboratory tests as short-term correlates of stroke
Sughrue, T., Swiernik, M. A., Huang, Y. H., & Brody, J. P. (2016) · BMC Neurology · doi:10.1186/s12883-016-0619-y · Cited by 13 · see citing works
“Electronic health records (EHRs) are rapidly being adopted by medical providers, and are now used by the majority of office-based physicians and hospitals in the US [6, 7].”
BackgroundElectronic health record competency in graduate nurses: A grounded theory study
Weinschreider, J., Tenzek, K. E., Foltz-Ramos, K., et al. (2023) · Nurse Education Today · doi:10.1016/j.nedt.2023.105987 · Cited by 13 · see citing works
Saurin, T. A., Patriarca, R., Hegde, S., & Rayo, M. F. (2024) · Applied Ergonomics · doi:10.1016/j.apergo.2024.104290 · Cited by 14 · see citing works
Fadahunsi, K. P., Wark, P. A., Mastellos, N., Neves, A. L., Gallagher, J., Majeed, A., Webster, A. P., Smith, A., Choo‐Kang, B., Leon, C., et al. (2022) · Journal of Medical Internet Research · doi:10.2196/41889 · Cited by 12 · see citing works
“However, the quality of information obtained from DHTs varies and can compromise quality and safety of care [2-4].”
A Shared Opportunity for Improving Electronic Medical Record Data
Baier, A. W., Snyder, D., Leahy, I. C., Patak, L. S., & Brustowicz, R. M. (2017) · Anesthesia & Analgesia · doi:10.1213/ane.0000000000002134 · Cited by 11 · see citing works
Analysis of variations in the display of drug names in computerized prescriber-order-entry systems
Quist, A., Hickman, T.-T. T., Amato, M. G., et al. (2017) · American Journal of Health-System Pharmacy · doi:10.2146/ajhp151051 · Cited by 11 · see citing works
Modeling the mind: How do we design effective decision-support?
Weir, C. R., Rubin, M. A., Nebeker, J. R., & Samore, M. H. (2017) · Journal of Biomedical Informatics · doi:10.1016/j.jbi.2017.06.008 · Cited by 11 · see citing works
A Sociotechnical Approach to Electronic Health Record Related Safety
Sittig, D. F., & Singh, H. (2017) · Elsevier eBooks · doi:10.1016/b978-0-12-809523-2.00014-5 · Cited by 11 · see citing works
Self-citationCampione, J. R., Mardon, R. E., & McDonald, K. M. (2018) · Journal of Patient Safety · doi:10.1097/pts.0000000000000531 · Cited by 10 · see citing works
Heed, J., Klein, S., Slee, A., et al. (2022) · British Journal of Clinical Pharmacology · doi:10.1111/bcp.15284 · Cited by 11 · see citing works
“Overuse of alerts or inappropriate alerting results in alert fatigue and a high incidence of alert overrides, which can adversely affect patient safety.(11) Van de Sijs et al.”
BackgroundHave Electronic Health Records Improved the Quality of Patient Care?
Krenn, L., & Schlossman, D. (2017) · PM&R · doi:10.1016/j.pmrj.2017.04.001 · Cited by 8 · see citing works
“A majority of providers cite remote access as one of the key benefits of having an EHR [7].”
BackgroundStakeholder perspectives of system-related errors: Types, contributing factors, and consequences
Kinlay, M., Zheng, W. Y., Burke, R. A., Juraskova, I., Ho, L. M., Turton, H., Trinh, J., & Baysari, M. T. (2022) · International Journal of Medical Informatics · doi:10.1016/j.ijmedinf.2022.104821 · Cited by 9 · see citing works
Ong, M., Sylvia Pelayo, A., & Issues, S. E. F. T. I. Y. S. O. H. F. A. O. (2015) · Yearbook of Medical Informatics · doi:10.15265/iy-2015-033 · Cited by 9 · see citing works
“Two papers were already selected in two other sections [20-21], and were removed from the HFOI selection, because considered to be better relevant to these sections.”
BackgroundHealth information systems´ usability-related use errors in patient safety incidents
Hautamäki, E., Kinnunen, U., & Palojoki, S. (2017) · Finnish Journal of eHealth and eWelfare · doi:10.23996/fjhw.60763 · Cited by 10 · see citing works
“units and date formats), wording and functions [5,6], patient identification issues [6,7,9], navigation difficulties [6,7], and wrong or missing data input [7,910].”
BackgroundInfluentialA hospital-wide transition from paper to digital problem-oriented clinical notes
Cillessen, F., Robbé, P. D. V., & Biermans, M. C. J. (2017) · Applied Clinical Informatics · doi:10.4338/aci-2016-08-ra-0137 · Cited by 10 · see citing works
Despins, L. A., & Wakefield, B. J. (2018) · CIN Computers Informatics Nursing · doi:10.1097/cin.0000000000000431 · Cited by 10 · see citing works
“Others have observed poor alignment of the EMR with assessment workflows, noting an inadequate fit between information needs and the task to be performed.(30,46)”
BackgroundReal-Time Automated Hazard Detection Framework for Health Information Technology Systems
Omitaomu, O. A., Özmen, Ö., Olama, M. M., Pullum, L., Kuruganti, T. P., Nutaro, J. J., Klasky, H. B., Zandi, H., Advani, A. A., Laurio, A., et al. (2019) · Health Systems · doi:10.1080/20476965.2019.1599701 · Cited by 11 · see citing works
“These concerns cover hazards that pose immense threats to patient safety as reported in multiple studies (e.g., Graber, Johnston, & Bailey, 2016; Magrabi, Ong, Runciman, & Coiera, 2011; Meeks et al., 2014; Wright et al., 2016).”
BackgroundSelf-citationAll CLEAR? Preparing for IT Downtime
Kashiwagi, D. T., Sexton, M. D., Graves, C., Johnson, J. M., Callies, B. I., Yu, R. C., & Thompson, J. M. (2016) · American Journal of Medical Quality · doi:10.1177/1062860616667546 · Cited by 9 · see citing works
Firdaus, M. (2019) · Jurnal Administrasi Rumah Sakit Indonesia · doi:10.7454/arsi.v6i1.2880 · Cited by 9 · see citing works
- Authors
- Meeks, D. W., Smith, M. W., Taylor, L., Sittig, D. F., Scott, J. M., & Singh, H.
- Affiliations
- Michael E. DeBakey VA Medical Center (US)
- United States Department of Veterans Affairs (US)
- Memorial Hermann (US)
- Corresponding author
- Singh, Hardeep
- Venue
- Journal of the American Medical Informatics Association
- Publisher
- Oxford University Press (OUP)
- Published
- 2014-11
- Volume
- 21
- Issue
- 6
- Pages
- 1053-1059
- ISSN
- 1067-5027 (ISSN-L)
- 1527-974X
- PMC
- PMC4215044
- OpenAlex
- W2148595420
- Semantic Scholar
- 9b75d5d6ec4e36813fe145af295d58b9926d0372
- Cited by
- 207
- References
- 60
- Citations by year
- 2026: 6 · 2025: 9 · 2024: 16 · 2023: 13 · 2022: 14 · 2021: 15 · 2020: 10 · 2019: 24 · 2018: 22 · 2017: 25 · 2016: 30 · 2015: 20 · 2014: 2
- FWCI
- 46.82
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Licence
- cc-by-nc-nd
- Locations
- Journal of the American Medical Informatics Association (publishedVersion, cc-by-nc-nd)
- Europe PMC (PubMed Central) (publishedVersion, cc-by-nc)
- PubMed Central (publishedVersion, cc-by-nc)
- PubMed (publishedVersion)
- Funders
- U.S. Department of Veterans Affairs (14-274, CIN13-413, USA 14-274)
- Office of Research and Development (CIN 13-413)
- Health Services Research and Development (CIN 13‐413, CRE12-033, USA 14-274)
- Agency for Healthcare Research and Quality (R01HS022087)
- U.S. Public Health Service (T32HP10031)
- Center for Innovations in Quality, Effectiveness and Safety (CIN 13–413, 13–413)
- Topics
- Health Sciences › Health Professions › Health Information Management › Electronic Health Records Systems
- Health Sciences › Health Professions › Emergency Medical Services › Patient Safety and Medication Errors
- Health Sciences › Health Professions › Health Information Management › Medical Coding and Health Information
- Keywords
- electronic health records, patient safety, socio-technical model, near misses, software upgrade, data transmission, hidden dependencies, workflow, EHR implementation, safety reporting, Veterans Health Administration
- MeSH terms
- Humans, Retrospective Studies, United States, United States Department of Veterans Affairs, Medical Errors, Workflow, Electronic Health Records, Patient Safety
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-07.
Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-07.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
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