Medication Safety During EHR Transition: Anticipating the Inevitable Risk Shift

Special Insights

Written by:

Lisaine Borges, PharmD, BCPS, BCCCP

The implementation of digital systems such as electronic health records (EHRs) has standardized documentation across healthcare systems, providers, and patients.

EHRs enable the electronic storage of patient information, including medical history, medications, test results, and treatments (Centers for Medicare & Medicaid Services [CMS], 2024).

Although no national benchmark exists for EHR replacement, transitions between systems are increasingly common as organizations pursue interoperability, consolidation, and enhanced functionality.

Systematic reviews highlight that EHR-to-EHR transitions have become a significant phase in the health information technology lifecycle (Miake-Lye et al., 2023; Rinne et al., 2023; Saleem & Herout, 2018).

While transition planning often emphasizes financial, interoperability, workflow, and resource considerations, the immediate impact on medication safety is less well defined.

Although EHR adoption is associated with improved medication safety, benefits are typically achieved only after systems mature and users gain experience. A meta-analysis reported a 26% reduction in medication errors, primarily in organizations with at least three years of EHR use (Mwogosi et al.,2025).

In contrast, transitions to new EHRs are associated with temporary increases in medication safety events. For example, one academic health system observed a fivefold increase in reported events after implementation, returning to baseline within three months (Whalen et al., 2018).

Transitions are also associated with shifts in error types, including increases in near-miss events and changes in reconciliation, ordering, and prescribing errors (Lindén-Lahti et al., 2022; Whalen et al., 2018).

A key factor influencing medication safety during transitions is disruption to workflow and system usability. The introduction of new technology alters navigation patterns, task sequencing, and cognitive workload.

During early implementation phases, unfamiliar interfaces and redesigned workflows can increase cognitive burden and reduce efficiency, creating opportunities for error that can propagate across prescribing, dispensing, and administration processes.

Medication reconciliation is particularly vulnerable during EHR transitions due to fragmented data sources and workflow redesign.

Within prescribing and computerized provider order entry (CPOE), transitions often result in changes to how orders are displayed and accessed. Order sets may be incomplete or absent due to prioritization during system build, forcing reliance on non-standardized workflows. Errors may also arise from misconfigured orders, including incorrect defaults or dosing fields.

Mitigation strategies include optimizing order sets before go-live, incorporating frontline clinician input, minimizing unnecessary dropdown selections, and validating names, synonyms, and visual presentation to support safe and intuitive prescribing practices.

Medication reconciliation is particularly vulnerable during EHR transitions due to fragmented data sources and workflow redesign. Incomplete medication histories, reconciliation gaps, and data migration issues can result in duplications, omissions, or unintended continuation of medications across levels of care.

Mitigation requires pharmacy-led medication history verification, standardized reconciliation workflows, and clearly defined ownership supported by system-level processes beyond pharmacy alone prior to implementation.

Order verification, medication preparation, and dispensing are also impacted. Increased cognitive load among pharmacy staff may contribute to missed clinical decision support alerts or overlooked discrepancies.

Interoperability challenges with automated dispensing cabinets (ADCs), medication database inconsistencies, and issues with National Drug Code (NDC) mapping further increase risk. Intravenous (IV) and infusion workflows are especially complex due to their reliance on integrated systems.

Mitigation includes enhanced staffing during go-live, targeted training, validation of medication databases, and end-to-end workflow testing.

Clinical decision support systems may contribute to alert fatigue if over-alerting occurs or if alerts are poorly aligned with organizational needs.

Conversely, ineffective or irrelevant alerts can reduce clinician trust. Mitigation requires careful customization, prioritization of high-value alerts, and ongoing monitoring of alert performance.

Medication administration processes are similarly affected, particularly in barcode medication administration (BCMA).

System gaps may lead to workarounds that bypass safety checks, increasing the risk of administration errors.

Addressing these issues requires real-time communication mechanisms, rapid-response teams, and prioritization of frontline feedback to resolve system gaps promptly.

In summary, while EHR transitions temporarily increase medication safety risks, particularly due to workflow disruption and system usability challenges, a proactive, standardized, and multidisciplinary approach is essential to identify vulnerabilities, implement targeted mitigations, and ensure a safe and effective transition.

References:

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