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Table 2 Electronic prescribing and medication administration (ePA) features that contributed to perception of increased medication risk

From: The impact of implementing a hospital electronic prescribing and administration system on clinical pharmacists’ activities - a mixed methods study

ePA features Implications for practice Examples from pharmacist interviews
 1. System nudges users to do the ‘wrong’ thing These are risks that could be reduced with system improvements and/or better user training So the doctors will often just click whichever one [insulin] is first, which is often, say, a cartridge of one and the patient’s got a FlexPen and it’s the pen that’s being used” (Pharmacist 3; 2.9 years’ experience)
 2. System indiscriminately defaults to specific actions “Like the doctors saying they’ve prescribed antibiotics, but if it’s past a certain timeframe it’ll automatically like set the next time. If you prescribed it at like 10 am and it is twice a day, it’ll set to 10 pm and they don’t always remember to put like a stat [once only] dose to be given straight away” (Pharmacist 3; 2.9 years’ experience)
 3. System makes error less visible (than a paper drug chart) “I see a lot more duplication of prescriptions than I did on paper drug charts. I think that doctors are not necessarily looking at the drug chart properly in the same way that you might with a paper drug chart. Duplication is something I see day in, day out; they’re asked to prescribe something and they don’t seem to realise the patient’s already on it”. (Pharmacist 4, 6.5 years’ experience)
“So missed doses sometimes I think [on ePA] aren’t as apparent or there is a way that they can drop off … I think it [missed doses] was more apparent on a paper chart … So there are ways where you view the drug charts for a time period and you have to have your options and your settings… Your default setting at what you look at has to be like big enough or cover a time period that is big enough to show you things like that dose was missed yesterday. Because if you’re just looking at today’s drug administration then you won’t see that. So that’s kind of the system has created that. Whereas on a paper chart you would see kind of the prescription and it would show you all the days for that 14 days”. (Pharmacist 1, 4 years’ experience)
 4. System makes error more visible (than a paper drug chart) This is a safety feature that raises awareness of an error “I think missed doses are more obvious now. Obviously on paper you didn’t have this constant reminder, whereas on [the ePA system] now, after an hour has elapsed from the time it was due, the box goes red, the administration box goes red.” (Pharmacist 2; 1.5 years’ experience)
 5. ePA makes other key information less visible (compared to paper drug charts) This is a risk that could be reduced with system improvements and/or better user training “There’s also annotating some of the prescriptions as well for like therapeutic drug monitoring, which is probably a downside to [the ePA system] in some respects in that previously, for example, aminoglycosides, you would write ... gentamicin, the level less than 1, [then] you’d put a box as to when they need to take the level, you could tell them to take the level then give or take the level then hold; you don’t have the opportunity to do that on the drug chart or on the administration chart on the electronic prescribing the way you could on a paper drug chart”. (Pharmacist 4; 6.5 years’ experience)
 6. System clinical decision support not meeting users’ expectations This is a risk that could be reduced with better user training “Doctors … they prescribe something after 8 am and it doesn’t flag then as being due until the next day.” (Pharmacist 2; 1.5 years’ experience)