J Am Med Inform Assoc 21:1053-1059 doi:10.1136/amiajnl-2013-002578
  • Research and applications

An analysis of electronic health record-related patient safety concerns

Open AccessPress Release
  1. Hardeep Singh1,3
  1. 1Houston VA Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
  2. 2Department of Family and Community Medicine, Baylor College of Medicine, Houston, Texas, USA
  3. 3Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
  4. 4Informatics Patient Safety, Office of Informatics and Analytics, Veterans Health Administration, Ann Arbor, MI and Albany, NY, USA
  5. 5University of Texas School of Biomedical Informatics and UT-Memorial Hermann Center for Healthcare Quality and Safety, Houston, Texas, USA
  1. Correspondence to Dr Hardeep Singh, Houston VA Center for Innovations in Quality, Effectiveness and Safety (152), 2002 Holcombe Boulevard, Houston, TX 77030, USA; hardeeps{at}
  • Received 12 December 2013
  • Revised 25 April 2014
  • Accepted 29 April 2014
  • Published Online First 20 June 2014


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.

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 3.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:

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