Identifying Health Information Technology Usability Issues Contributing to Medication Errors Across Medication Process Stages

J Patient Saf. 2021 Dec 1;17(8):e988-e994. doi: 10.1097/PTS.0000000000000868.


Objective: Different health information technology (health IT) systems are intended to support medication ordering, reviewing, and administration. We sought to identify the types of medication errors associated with health IT use, whether they reached the patient, where in the medication process those errors occurred, and the specific usability issues contributing to those errors.

Methods: Patient safety event reports from more than 595 healthcare facilities entered between January 2013 and September 2018 were analyzed. We computationally identified reports associated with health IT intended to support the medication process, including computerized provider order entry, electronic medication administration record, and barcode medication administration. From these, 2700 reports were manually reviewed to determine the type of medication error, medication process stage, and health IT usability issue.

Results: Of the 2700 manually reviewed reports, 1508 (55.9%) described a medication error that was associated with health IT use and 750 (49.7%) reached the patient. Improper dose errors were frequent (1214 of 1508, 80.5%) with most errors during ordering (673 of 1508, 44.6%) and reviewing medications (639 of 1508, 42.4%). Most health IT-associated medication error reports described usability issues (n = 1468 of 1508, 97.3%) including data entry, workflow support, and alerting. Data entry usability issues impacted few medication process stages, whereas workflow support and alerting impacted several stages.

Conclusions: Health IT usability issues are a prevalent contributing factor to medication errors, many of which reach the patient. Data entry, workflow support, and alerting should be prioritized during usability and safety optimization efforts.

Publication types

  • Research Support, N.I.H., Extramural

MeSH terms

  • Electronic Data Processing
  • Humans
  • Medical Order Entry Systems*
  • Medication Errors / prevention & control
  • Pharmaceutical Preparations*
  • Workflow


  • Pharmaceutical Preparations