Specifically, when prescribers were forced by the CPOE system to select brand name insulin from a list of similar-looking brand names, they could inadvertently choose an incorrect type of insulin. Similarly, in a case study of electronic prescribing for patients with diabetes in a safety net clinic, investigators found overspecification to be a source of medication errors in both insulin ordering and insulin use. In the ICU study, the CPOE system required physicians to select the medication schedule, a function that nurses or pharmacists may be better prepared to do (and had historically done) in inpatient settings. One source of technology-induced error was overspecification of functions within the CPOE module. For example, a detailed study of types and rates of medication safety events before and after EHR implementation in two ICUs found that, while overall medication safety improved, new vulnerabilities emerged, including increases in wrong patient, wrong medication, or wrongly timed orders. One theme of the literature on EHR implementation is the emergence of unanticipated consequences. Similar findings were reported in a review of nurses' experiences with EHR use, which highlighted the altered workflow and communication patterns created by the implementation of EHRs. Additional safety hazards included data entry errors created by the use of copy-forward, copy-and-paste, and electronic signatures, lack of clarity in sources and date of information presented, alert fatigue, and other usability problems that can contribute to error. The latter problems resulted in interruptions and distraction, which can contribute to medical error. These included usability issues, such as poor information display, complicated screen sequences and navigation, and mismatch between user workflow in the EHR and clinical workflow. However, the investigators found a number of problems as well. In a review of EHR safety and usability, investigators found that the switch from paper records to EHRs led to decreases in medication errors, improved guideline adherence, and (after initial implementation) enhanced safety attitudes and job satisfaction among physicians. However, the transition to this new way of recording and communicating medical information has also introduced new opportunities for error and other unanticipated consequences that can present safety risks. Ideally, the system creates a seamless, legible, comprehensive, and enduring record of a patient's medical history and treatment. EHR systems are made up of the electronic patient "chart" and typically include functionality for computerized provider order entry (CPOE), laboratory and imaging reporting, and medical device interfaces. Electronic health records (EHRs) have been widely adopted over the past decade in both inpatient and outpatient settings.
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