The DOI matches its Crossref record; 51 of the 52 references it cites were found in a registry or an index; none of the 48 sources its claims cite is checked for support yet.
EHR Safety: The Way Forward to Safe and Effective Systems
Open accessAbstract
Diverse stakeholders--clinicians, researchers, business leaders, policy makers, and the public--have good reason to believe that the effective use of electronic health care records (EHRs) is essential to meaningful advances in health care quality and patient safety. However, several reports have documented the potential of EHRs to contribute to health care system flaws and patient harm. As organizations (including small hospitals and physician practices) with limited resources for care-process transformation, human-factors engineering, software safety, and project management begin to use EHRs, the chance of EHR-associated harm may increase. The authors propose a coordinated set of steps to advance the practice and theory of safe EHR design, implementation, and continuous improvement. These include setting EHR implementation in the context of health care process improvement, building safety into the specification and design of EHRs, safety testing and reporting, and rapid communication of EHR-related safety flaws and incidents.
Overview
Integrity signals
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Claims the paper makes
23 Not checked yet · 2 Own interpretation · 1 No basis given
In the paper
“In those organizations, including those of the authors, clinicians regard easy access to test results, clinician observations, clinical-decision support, and e-messaging as vital to care quality and patient safety.”
§ EHR Safety: The Way Forward to Safe and Effective Systems > EHR Safety and Effectiveness
What the sources say
- Not checked yetcites [1] source
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
In the paper
“The third study, conducted in a subpopulation of a children's hospital, documented a doubling of mortality (from 2.8% to 6.6%) after CPOE implementation.23”
§ EHR Safety: The Way Forward to Safe and Effective Systems > EHR Safety and Effectiveness
What the sources say
- Not checked yetcites [23] source
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
None of the sources cited for this claim have been checked yet.
In the paper
“The identification of EHR-related flaws increases markedly with every new software deployment (both original implementations and upgrades).22,42”
§ EHR Safety: The Way Forward to Safe and Effective Systems > Prevent and Manage EHR-related Incidents
What the sources say
- Not checked yetcites [22] source
- Not checked yetcites [42]
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
In the paper
“The fourth study, conducted in the same hospital, showed no significant change in mortality.24”
§ EHR Safety: The Way Forward to Safe and Effective Systems > EHR Safety and Effectiveness
What the sources say
- Not checked yetcites [24] source
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: unclear — It is unclear whether the paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
None of the sources cited for this claim have been checked yet.
In the paper
“Although the first two studies have been widely cited as showing CPOE benefits, neither showed improvements in patient outcomes.20 -22”
§ EHR Safety: The Way Forward to Safe and Effective Systems > EHR Safety and Effectiveness
What the sources say
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
None of the sources cited for this claim have been checked yet.
In the paper
“Complicating matters, the health care literature documents the potential of EHRs to contribute to safety incidents and patient harm.1,23,30 -33”
§ EHR Safety: The Way Forward to Safe and Effective Systems > EHR-related Safety Flaws
What the sources say
plainconditional- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
None of the sources cited for this claim have been checked yet.
In the paper
“Although some measures of error showed improvement, overall safety and effectiveness have been addressed in only five studies.[21][22][23][24][25]”
§ EHR Safety: The Way Forward to Safe and Effective Systems > EHR Safety and Effectiveness
What the sources say
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
The paper states this without a source or data behind it here, so there is nothing to check it against. The quote shows it is in the paper.
In the paper
“Assessing the overall safety and effectiveness of EHR use is made difficult by the limited research literature.”
§ EHR Safety: The Way Forward to Safe and Effective Systems > EHR Safety and Effectiveness
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
None of the sources cited for this claim have been checked yet.
In the paper
“Published reports of CPOE-related errors have provided initial, high-level typologies of safety incidents.30,44,45”
§ EHR Safety: The Way Forward to Safe and Effective Systems > Communicate Safety Flaws and Incidents
What the sources say
- Not checked yetcites [30] source
- Not checked yetcites [44]
- Not checked yetcites [45]
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Because of this extensive customization (a type of overfitting), reports of EHR-related effectiveness from these organizationsalthough important as efficacy studies-may not be generalizable to the less customized EHRs and EHR implementations that most organizations will use.”
§ EHR Safety: The Way Forward to Safe and Effective Systems > Introduction
hedgedconditional- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
- Rests on an assumption: The decades-long iterative development of early EHRs improved the fit between the software and the organization, users, and care processes.
- Rests on an assumption: In the first organizations to use EHRs, software designers knew the organization, the users, and the care processes the EHR was meant to support.
- It may state two separate claims as one. 6
- Probably not a substantial claim. 2
None of the sources cited for this claim have been checked yet.
In the paper
“Because EHRs are particularly complex technology innovations-affecting workflows, communications, job definitions, working conditions, and job security-demonstrat-ing and improving their safety is critically important.[5][6][7][8][9][10]”
§ EHR Safety: The Way Forward to Safe and Effective Systems > Introduction
What the sources say
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
In the paper
“The fifth study found that only thirty-one percent of physicians and fifty-six percent of nurses believed that the EHR contributed to improvement of care overall.25”
§ EHR Safety: The Way Forward to Safe and Effective Systems > EHR Safety and Effectiveness
What the sources say
- Not checked yetcites [25] source
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: unclear — It is unclear whether the paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
None of the sources cited for this claim have been checked yet.
In the paper
“This approach will reinforce the fact that safe and effective use of an EHR requires new organizational policies, processes, work systems, job descriptions, and education.38,39”
§ EHR Safety: The Way Forward to Safe and Effective Systems > Use EHRs as Tools for Health Care Process Improvement
What the sources say
- Not checked yetcites [38]
- Not checked yetcites [39]
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim.
In the paper
“In fact, the second study reported an increase in medication errors and adverse drug events, which was reversed after an improvement in the CPOE interface.22”
§ EHR Safety: The Way Forward to Safe and Effective Systems > EHR Safety and Effectiveness
What the sources say
- Not checked yetcites [22] source
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
In the paper
“A more recent systematic review of health care information technology (largely EHRs) by Chaudhry et al. concluded that in most health care settings, it may be difficult “to determine what benefits to expect from health information technology use and how best to implement the system in order to maximize the value derived.”27”
§ EHR Safety: The Way Forward to Safe and Effective Systems > EHR Safety and Effectiveness
What the sources say
- Not checked yetcites [27] source
hedged- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. It may state two separate claims as one.
None of the sources cited for this claim have been checked yet.
In the paper
“The few available studies have largely been conducted by the developers of the EHRs and have focused on the effect of order entry (CPOE) systems on a limited number of error types.[17][18][19][20]”
§ EHR Safety: The Way Forward to Safe and Effective Systems > EHR Safety and Effectiveness
What the sources say
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
In the paper
“A systematic review of outpatient CPOE systems found only four studies that addressed safety and concluded, “the relatively small number of evaluation studies published to date do not provide adequate evidence that CPOE systems enhance safety and reduce cost in the outpatient settings.”28”
§ EHR Safety: The Way Forward to Safe and Effective Systems > EHR Safety and Effectiveness
What the sources say
- Not checked yetcites [28] source
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
The paper relies on this without support.
Widespread EHR adoption is necessary to achieve many American health care goals, including better care quality and patient safety.
“There is a growing consensus that widespread adoption of electronic health care records (EHRs) is essential to achieving many American health care goals, including improved care quality and patient safety”
The paper relies on this without support.
The benefits of well-managed EHRs are probably substantial.
“Although the benefits of well-managed EHRs may seem obvious and are likely substantial”
The paper relies on this without support.
Few EHR risk-management strategies have been published.
“Few EHR risk-management strategies have been published.”
The paper relies on this without support.
No published research identifies a comprehensive set of effective risk-reduction activities.
“In the absence of published research that identifies a comprehensive set of effective risk-reduction activities”
The paper relies on this without support.
Most EHR-related safety flaws are found and fixed before they cause a safety incident.
“Most of these flaws are identified and mitigated before a safety incident occurs.”
The paper relies on this without support.
A small fraction (anecdotally less than 0.1%) of flaws are discovered only after they contribute to an incident.
“A small number (anecdotally, Ͻ0.1%) are discovered after they contribute to an incident (for example, a medication administration error).”
The paper relies on this without support.
Smaller hospitals and most physician practices likely lack the resources to mount such an initiative.
“Smaller hospitals and most physician practices are unlikely to have the resources to mount such an initiative.”
The paper relies on this without support.
The decades-long iterative development of early EHRs improved the fit between the software and the organization, users, and care processes.
“The decades-long, iterative development process that these early EHRs went through improved the fit between the software and the organization, the users, and the care processes.”
The paper relies on this without support.
In the first organizations to use EHRs, software designers knew the organization, the users, and the care processes the EHR was meant to support.
“In the first organizations to use EHRs, software designers knew the organization, the EHR's users, and the specific care processes the EHR was meant to support.”
The paper relies on this without support.
Changing a complex EHR after development or implementation is extremely difficult, error-prone, and expensive.
“Changing a software system as complex as an EHR after it has been developed (or implemented) is enormously difficult, error-prone, and expensive.”
The paper relies on this without support.
Local EHR implementation and continuous-improvement teams make many decisions that can create system-safety flaws.
“Local EHR implementation and continuous-improvement teams make many decisions-regarding organizational policies, work processes, and software configurations-that have the potential to create system-safety flaws.”
The paper relies on this without support.
Some EHR flaws originate in the vendor's software creation process, while others come from the customer or from interactions between the EHR and other systems; the distinction is often hard to make.
“Some of these flaws will turn out to be related to the vendor's software creation process; others will have been introduced by the customer or by interactions between the EHR and other health care systems.Often, this distinction will be difficult to make.”
The paper relies on this without support.
A well-designed taxonomy of EHR-related system safety flaws and safety incidents has not yet been developed.
“The clearinghouse should be based on a well-designed taxonomy of EHR-related system safety flaws and safety incidents, which has yet to be developed.”
The paper relies on this without support.
Knowledge about how to develop, implement, and continuously improve EHRs for patient safety is currently limited and inaccessible to most health care organizations.
“Knowledge of how to develop, implement, and continuously improve EHRs for patient safety is currently limited and not accessible to most health care organizations.”
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?
The source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“However, existing classifications, including AIMS and the ICPS, 18 fall short with respect to computer-related incidents as this source of risk has yet to be systematically examined.20”
From An analysis of computer-related patient safety incidents to inform the development of a classification (2010) · cites this paper as [20]
Experimental — accuracy not yet measuredIn the citing paper
“Indeed, incident reporting to facilitate rapid communication of safety flaws and critical events arising from computer use is one of seven steps which have been proposed to improve the safety of healthcare IT. 20”
From An analysis of computer-related patient safety incidents to inform the development of a classification (2010) · cites this paper as [20]
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Metadata
- Authors
- Walker, J. M., Carayon, P., Leveson, N., Paulus, R. A., Tooker, J., Chin, H., Bothe, A., & Stewart, W. F.
- Affiliations
- Geisinger Health System (US)
- University of Wisconsin System (US)
- Massachusetts Institute of Technology (US)
- American College of Physicians (US)
- Kaiser Permanente (US)
- Geisinger Medical Center (US)
- Corresponding author
- Walker, J. M.
- Venue
- Journal of the American Medical Informatics Association
- Publisher
- Oxford University Press (OUP)
- Published
- 2008-05-01
- Volume
- 15
- Issue
- 3
- Pages
- 272-277
- ISSN
- 1067-5027 (ISSN-L)
- 1527-974X
- PMC
- PMC2409999
- OpenAlex
- W30038292
- Semantic Scholar
- e79e16206458fd09a10c7cd9fb2a73a9d5dfa8f9
- Cited by
- 113
- References
- 52
- Citations by year
- 2026: 1 · 2025: 2 · 2024: 4 · 2023: 7 · 2022: 1 · 2021: 1 · 2020: 4 · 2019: 10 · 2018: 1 · 2017: 8 · 2016: 6 · 2015: 8 · 2014: 11 · 2013: 8 · 2012: 7
- FWCI
- 24.15
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Journal of the American Medical Informatics Association (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Health Professions › Health Information Management › Electronic Health Records Systems
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Patient Safety and Medication Errors
- Health Sciences › Health Professions › Health Information Management › Medical Coding and Health Information
- Keywords
- electronic health records, patient safety, EHR design, EHR implementation, healthcare process improvement, human factors engineering, software safety, safety testing, safety reporting, incident communication, small hospitals, physician practice, quality of care
- MeSH terms
- Humans, Safety, Software, Medical Records Systems, Computerized, Medical Errors
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.
A language model drew the claims from the paper on 2026-10-07, under version 3 of the claim definition (model deepseek-v4.1-flash, prompt extract-v3).
A second model labelled each claim on 2026-10-07 (model jev-1.13-20260917, definition revision gold-guideline-v0.2).
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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