A female pharmacist stands behind a pharmacy counter using a desktop computer. Medicines line the shelves behind her.

Electronic patient record systems: recurring themes arising from safety investigations

By Helen Jones

19 December 2023

Senior Safety Investigator, Helen Jones, blogs about some of the key benefits and risks of electronic patient record (EPR) systems used in healthcare, sharing what we are learning from our safety investigations.

Electronic patient record (EPR) systems are used across the NHS landscape, with 90% of hospital trusts now having access to them.

These systems have the potential to be beneficial to patients and staff. However, the evidence we’ve gathered during six years of safety investigations (since the launch of our legacy organisation) highlights a variety of safety issues associated with EPR systems that can impact on patient safety if they are launched or used without a proactive view on their safety.

Given the recent news that the national technology budget will be cut by more than £300 million, and EPR budgets will likely be at risk, it is important that there remains a focus on how resources can best be focused on EPR systems, to improve patient safety.

Recurring themes identified through safety investigations

Since 2018, we have published nine investigations in which there were specific findings and safety recommendations relating to EPR systems. We also see some level of EPR issues in nearly every investigation we undertake.


A key finding in a number of our investigations was the lack of interoperability between the EPR and other IT systems across services. This relates to the ability of computer systems or software to exchange information.

Management of chronic health conditions in prisons

Martin, a 43-year-old inmate, suffered multiple seizures after his epilepsy medication was not transferred with him to a new prison. The error occurred because essential information could not be automatically shared across the healthcare records and the operational IT systems, due to interoperability.

Read the prisons report

Electronic prescribing and medicines administration systems and safe discharge

Ann, a 75-year-old, was discharged home taking two powerful blood thinning medications after a mix-up at her local hospital. We found a lack of interoperability between primary and secondary care systems, between secondary care facilities, between secondary and tertiary care, and between secondary care and community pharmacy.

Read the electronic prescribing report

Outpatient appointments intended but not booked after inpatient stays

Pauline, a 54-year-old woman, was discharged from hospital on two separate occasions with a plan to follow-up in outpatient clinics. However, neither of the outpatient appointments were made. A key finding in this case was that the lack of interoperability between IT systems adds complexity and increases the likelihood of error in the outpatient appointment booking process.

Read the outpatient appointments report

Usability testing of software

A key finding in a number of our investigations was that EPR systems had not undergone usability testing. This is a method of testing the functionality of an EPR system by observing real users as they attempt to complete tasks in the environment they work in.

Insertion of an incorrect intraocular lens

An 86-year-old woman had an incorrect lens inserted into her eye during planned cataract surgery. One of the main findings from the investigation related to the design of the software interface used, namely that it was prone to usability issues, even for those who were familiar with its operation.

Read the incorrect lens report

Weight-based medication errors in children

A four-year-old child suffered harm after receiving 10 times the intended dose of an anticoagulant on five separate occasions due to an undetected prescription error recorded on a medicines EPR system. We found that the usability and functionality of the EPR had not been assessed through user-testing across a range of different settings during the design process.

Read the medication errors in children report

Standards and standardisation of the software and systems

We have seen that the EPR systems staff are asked to use have not incorporated human factors engineering principles. Testing and standards can help ensure that staff and patient interactions with the EPR system can be better understood to help identify the systems strengths and weaknesses and identify potential errors that could result in harm to patients. During our investigations we have made safety recommendations to national organisations to help improve EPR systems by:

  • Ensuring EPR systems undergo human factors and usability assessments to ensure their functionality and safety for staff and patients.
  • Ensuring manufacturers are provided with additional guidance to meet the above requirements.
  • Commissioning research into how EPR systems can be best configured to avoid staff experiencing ‘alert fatigue’. This is where too many alerts may lead to users paying less attention to them.
  • Ensuring EPR systems consider the whole patient pathway in relation to discharge from hospital and not just acute care.
  • Improving interoperability between different systems in the prisons system.

The way forward

The new NHS ‘federated’ data platform will enable every NHS trust and integrated care system to connect and share information between them. This type of digitised, connected system would enable services to be delivered more effectively and efficiently, with the patient front and centre.

For this system, or any EPR system, to help ensure improved patient safety, organisations need to:

  • Plan for interoperability or what the process will be if EPR systems are not interoperable.
  • Utilise human factors and user-centred design input to help design systems to be the best they can be.
  • Commit to usability testing with the staff and patients who will use the system, in the environment the EPR system will be used in, to best reflect ‘real world’ work.

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