In case 1, there was a free text field that was utilized incorrectly and it resulted in an improper and dangerous drug given to a pediatric patient.  The EHR in this case needs to be revised and this free text field needs to be removed.  In this situation, the physician’s specific instructions should have been more visible, maybe printed (in bold and highlighted) right on the medication itself as well as in the patient’s medical record.  Another way this could have been prevented is if the EHR is be set up to alert the nurse after she scans the patient barcode to administer the meds if that medication order has specific instructions, such as this one did. 


For Case 3, there is some obvious display issues with this EHR.  The medication display needs to be altered so that it is obvious when meds are missed.  The EHR meds display needs to be set up so that all medications are displayed with the time they should be given and the time they WERE actually given.  This makes it easy to quickly look at the display and know what the patient needs.  The EHR also can be set up to remind the nurse when a patient is in need of a dose.  It can alert her if a dose is missed. 


For Case 12, a newborn immediately needed emergency treatment for a blood transfusion. Clinicians first had to enter the baby's weight and Apgar score into specific data fields on her patient chart to allow them to order the blood transfusion for her. The medical staff decided not to do these things for the sake of time and to not delay care, they instead went into the profile of her twin brother who already has the information needed to request one. To prevent something like this from happening again, the EHR should have something that allows clinicians to use their credentials to override the system to order things needed for an emergency situation instead of requiring them to enter excess information that takes up too much time. Another thing that could have prevented this from happening is if the EHR had an in-built communication system where the medical team working with the newborn could page the doctor for a blood transfusion immediately, instead of going into the twin brother's profile to order one potentially putting him at risk. 


The Pew Charitable Trusts. (2019, April 24).  Poor usability of electronic health records can lead to drug errors, jeopardizing pediatric patients. The Pew Charitable Trusts. Retrieved February 13, 2023, from


Case 9: Another way to set up the EHR to prevent medication errors from occurring would be to ensure that the EHR correctly processes medications that are to be administered through an automated dispensing machine versus those that are dispensed through the pharmacy. This could be achieved by improving communication between the EHR and the dispensing machine, ensuring that pharmacy staff is promptly notified of any medication orders, and creating alerts for clinicians if there is any delay in medication administration.

Case 10: To prevent this medication error from occurring, the EHR could be set up to clearly distinguish between drugs that are intended to be administered indefinitely and those set to be discontinued after a set duration. This could be achieved through interface improvements that make it easier for clinicians to identify the status of medication orders, including discontinuation orders. Additionally, the system could include alerts for clinicians to verify medication orders that have been automatically discontinued and require that the physician verify the reason for the discontinuation before the medication is actually discontinued.