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BMJ Qual Saf. 2019 Jul 18. pii: bmjqs-2019-009609. doi: 10.1136/bmjqs-2019-009609. [Epub ahead of print]

Assessing the safety of electronic health records: a national longitudinal study of medication-related decision support.

Author information

Harvard Business School, Harvard University, Boston, Massachusetts, USA
Department of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.
The Leapfrog Group, Washington, DC, USA.
Infectous Diseases, University of Utah, Salt Lake City, Utah, USA.



Electronic health records (EHR) can improve safety via computerised physician order entry with clinical decision support, designed in part to alert providers and prevent potential adverse drug events at entry and before they reach the patient. However, early evidence suggested performance at preventing adverse drug events was mixed.


We used data from a national, longitudinal sample of 1527 hospitals in the USA from 2009 to 2016 who took a safety performance assessment test using simulated medication orders to test how well their EHR prevented medication errors with potential for patient harm. We calculated the descriptive statistics on performance on the assessment over time, by years of hospital experience with the test and across hospital characteristics. Finally, we used ordinary least squares regression to identify hospital characteristics associated with higher test performance.


The average hospital EHR system correctly prevented only 54.0% of potential adverse drug events tested on the 44-order safety performance assessment in 2009; this rose to 61.6% in 2016. Hospitals that took the assessment multiple times performed better in subsequent years than those taking the test the first time, from 55.2% in the first year of test experience to 70.3% in the eighth, suggesting efforts to participate in voluntary self-assessment and improvement may be helpful in improving medication safety performance.


Hospital medication order safety performance has improved over time but is far from perfect. The specifics of EHR medication safety implementation and improvement play a key role in realising the benefits of computerising prescribing, as organisations have substantial latitude in terms of what they implement. Intentional quality improvement efforts appear to be a critical part of high safety performance and may indicate the importance of a culture of safety.


decision support, computerised; hospital medicine; information technology; medication safety; patient safety


Conflict of interest statement

Competing interests: DB reported consulting for EarlySense, which makes patient safety monitoring systems; receiving cash compensation from CDI (Negev), which is a not-for-profit incubator for health internet technology start-ups; receiving equity from Valera Health, which makes software to help patients with chronic diseases; CLEW, which makes software to support clinical decision-making in intensive care; and MDClone, which takes clinical data and produces deidentified versions of it. DC is an employee of Pascal Metrics, a federally certified patient safety organisation.

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