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JOURNAL OF ADVANCED NURSING

SHORT REPORT

Nurses perceptions of an electronic patient record from a patient safety

perspective: a qualitative study
Jean E. Stevenson & Gunilla Nilsson
Accepted for publication 11 June 2011

Correspondence to J.E. Stevenson:

e-mail: jean.stevenson.agren@lnu.se
Jean E. Stevenson BA MSc RN
Lecturer
School of Language and Literature, Linnaeus
University, Kalmar, Sweden
Gunilla Nilsson PhD RN
Associate Professor of Nursing and Health
Informatics
School of Health and Nursing, Linnaeus
University, Kalmar, Sweden

S T E V E N S O N J . E . & N I L S S O N G . ( 2 0 1 2 ) Nurses perceptions of an electronic

patient record from a patient safety perspective: a qualitative study. Journal of
Advanced Nursing 68(3), 667676. doi: 10.1111/j.1365-2648.2011.05786.x

Abstract
Aims. The overall aim of this study was to explore nurses perceptions of using an
electronic patient record in everyday practice, in general ward settings. This paper
reports on the patient safety aspects revealed in the study.
Background. Electronic patient records are widely used and becoming the main
method of nursing documentation. Emerging evidence suggests that they fail to
capture the essence of clinical practice and support the most frequent end-users:
nurses. The impact of using electronic patient records in general ward settings is
under-explored.
Method. In 2008, focus group interviews were conducted with 21 Registered
Nurses. This was a qualitative study and the data were analysed by content analysis.
At the time of data collection, the electronic patient record system had been in use
for approximately 1 year.
Findings. The findings related to patient safety were clustered in one main category:
documentation in everyday practise. There were three sub-categories: vital signs,
overview and medication module. Nurses reported that the electronic patient record
did not support nursing practice when documenting crucial patient information,
such as vital signs.
Conclusions. Efforts should be made to include the views of nurses when designing
an electronic patient record to ensure it suits the needs of nursing practice and
supports patient safety. Essential patient information needs to be easily accessible
and give support for decision-making.
Keywords: acute hospital settings, documentation, electronic patient records, focus
group interviews, patient safety, record keeping, supporting nursing practice

Introduction
Patient safety and nursing documentation are internationally
important aspects of patient care. Patients admitted to
hospital have the right to expect optimal care (Department
of Health 2008). In the event that a patients condition
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Journal of Advanced Nursing  2011 Blackwell Publishing Ltd

should deteriorate, it is assumed that timely and appropriate

action will be taken. However, according to the National
Institute of Clinical Excellence NHS UK, sometimes deterioration in patients clinical status is not detected or acted
upon in time, leading to potentially fatal outcomes (NICE
2007). In addition, it is possible that complex documentation
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J.E. Stevenson and G. Nilsson

in electronic patient records may be compounding this

problem, although we have been unable to find such evidence
in the literature. Patient safety is a primary concern for nurses
(Feng et al. 2008) and their perceptions of patient safety in
electronic patient records (EPR) are important as they are the
largest group of healthcare workers and the professionals
who are with patients round the clock (Clark 2007).
Although this study represents only one EPR system in one
hospital, we believe there are important universal lessons
about system design, patient vigilance and patient safety,
which can be applied to any EPR system. Our main study
highlighted several aspects of nurses experiences of the EPR
in general ward settings. In this article we only present the
patient safety issues which emerged.

Background
Healthcare information systems have evolved to play a
major role in health care in modern society and the EPR
aims to improve patient safety and documentation quality
(Granlien et al. 2008). Nurses play a pivotal role in patient
safety and studies from across the world confirm that the
quality of the nursing environment has a direct impact on
patient outcomes (Clarke & Aiken 2005). Nurses are handson carers so their contribution to health care clearly affects
patient safety (Burhans & Alligood 2010). Also, according
to the Institute of Medicine, nursing vigilance protects
patients from errors (IOM 2004). Finally, on-going vigilance
is vital for the early detection and prevention of potential
problems (Despins et al. 2009).
The need for excellent patient vigilance is currently
emphasized. To begin with, there is an increasingly complex
group of older patients with multiple diagnoses, routinely
treated in acute care settings (Armitage et al. 2007, James
et al. 2010). Moreover, acute hospitals tend to manage only
the seriously ill, because length of stay has greatly decreased
(Hillman et al. 2001). Therefore, good-quality routines for
documenting physiological status in adult patients are essential, as patients are at risk of becoming acutely ill due to their
underlying diagnoses or previous medical condition. Furthermore, many studies have shown that careful monitoring of a
patients physiological status, early recognition of deterioration and timely management can greatly reduce the incidence
of cardiac arrest and unplanned admission to critical care
units (Buist et al. 2002, Andrews & Waterman 2005,
McBride et al. 2005, Gardner-Thorpe et al. 2006, Armitage
et al. 2007, NICE 2007).
Criteria for detecting patient deterioration include respiratory rate, systolic blood pressure, heart rate, conscious
level and temperature. According to NICE (2007), these
668

parameters need to be done well and recorded well.

In addition, these should be easily viewed so that changes
in trends can be instantly identified by all clinicians (Hutson
& Millar 2009). Traditional visual views of vital signs in
graphical form on paper charts are being replaced by
electronic formats in the EPR, so it is important that this
clinical documentation is comprehensively presented.
However, previous studies have shown that, despite some
positive views, for example, improved legibility, nurses were
predominantly dissatisfied with EPR systems (Stevenson
et al. 2010). This was largely due to lack of an efficient
way to view an overall picture of patient progress and care,
and poor navigability (Darbyshire 2000, 2003, Timmons
2003, Moody et al. 2004, Smith et al. 2005, Lind 2007).
Although technophobia and resistance to technology have
been blamed, nurses have had minimal influence in the
design of systems (Clark 2007) and therefore, some claim
that perceived resistance to EPR is more accurately explained
by nurses defying poorly designed systems that fail to meet
the needs of documentation in nursing practice (Timmons
2003). As there is a dearth of studies on nurses experience of
EPR in general wards, this study was designed to increase
knowledge of nurses experiences by investigating their
perceptions of using the EPR for documentation in everyday
practice.

The study
Aim
This study aims to explore nurses perceptions of using
electronic patient records in everyday practice, in general
ward settings.

Design
A qualitative design was selected, where data were collected
through focus group interviews and analysed by means of
content analysis. This article forms part of a larger study on
nurses perceptions of using EPR.

Participants
The participants were Registered Nurses (RNs), (hereinafter,
referred to as nurses) who worked in a district general
hospital in the southeast of Sweden. A letter explaining the
purpose of the study was sent to six acute wards and nurses
who wanted to participate could volunteer. The inclusion
criteria were that participants were RNs, from acute clinical
areas (medical/surgical wards) where an EPR was used for
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Patient safety in an electronic patient record

clinical documentation. Nurses (n = 21) responded voluntarily from six wards; two medical (n = 5), two surgical (n = 6),
one orthopaedic (n = 4) and a stroke unit (n = 6). At the time
of data collection, the EPR system had been in place for
approximately 1 year in all the wards.

Data collection
The data were collected within a 2-week period in November and December 2008. A total of four focus group
interviews was conducted, each lasting between 50 and
80 minutes with a mean of 65 minutes. Two researchers, the
authors, carried out the interviews in quiet conference rooms
adjacent to the wards in which the nurses worked. The
researchers were university lecturers and, apart from recognizing one previous student in one of the groups, the
researchers were not acquainted with any of the nurses. The
nurses and researchers sat round a table in a circle. Each
interview was audio-recorded digitally. There was no specific
interview guide, as we wanted the nurses to speak freely
about their perceptions of the EPR. A general question was
asked at the beginning which covered the broad aim of the
study. The question was: What are your experiences of
using electronic patient record systems in your everyday
work?
Although an unstructured approach was taken, when
necessary, probing questions were added by the researchers
to gain more information, for example, to describe something
in more detail, such as describe what you mean by journal.
In each interview, the introductory question initiated an
immediate response and a free flow of dialogue. Towards the
end of each interview, when the researchers considered that
saturation point had been reached, a so-called round robin
was initiated, whereby each respondent was asked to state
something they found positive and something they found
negative about the EPR system. It was clear that focus group
interviews provided a good climate for discussion and gave
the nurses an opportunity to reflect on their experiences
as a group; hence, enriching the information they shared
(McLafferty 2004). Citations from all interviewees were
included to validate the findings.

Ethical considerations
The study was approved by the appropriate university and the
Ethics Committee of Southeast Sweden. Permission to perform
the focus group interviews was obtained from the managers of
the three hospital departments involved in the study; surgical,
medical and orthopaedics. Information about the study was
given to potential participants. The nurses who volunteered
(n = 21) gave their consent to participate in the study and were
informed that they could withdraw from the study at any time.
Confidentiality of the participants was guaranteed by removing any identifying features from the transcripts.

Data analysis
The digital audio-recordings of the interviews were transcribed verbatim and content analysis was carried out as
proposed by Graneheim and Lundman (2004). The process
began by reading through the interview transcripts several
times and sometimes returning to interview recordings to
become completely familiar with the data and to comprehend
its essential features. The raw data were processed by opencoding (JS): writing notes and headings in the margins while
reading, to include all aspects of the content which related to
the aim of the study. Meaning units were identified and
colour-highlighted on a word-processor. Subsequently, these
were transferred to a coding sheet. The meaning units were
condensed to give a manifest description of the content and
then coded according to content. Sub-categories were identified according to similar codes. Finally, main categories
(of which only one is included in this report) were established
where similar elements of the sub-categories could be
combined. Both authors discussed the categories until
consensus was reached. Checking and rechecking the categories led to total immersion and interaction with the data in
the spirit of insightful interpretation (Polit & Beck 2008).
Examples of the process of content analysis of small pieces of
text are illustrated in Table 1.
The authors discussed and revised coding until general
agreement concerning categories and sub-categories was
reached (Table 2). Herein we present only one of the

Table 1 Example of the analysis process: from meaning units to category

Meaning unit

Condensed meaning unit

Code

Sub-category

Category

It takes a long time before you

can even begin to understand a
little and even then I might have
missed something

Understanding
patient history
and status

Patient safety

Difficult to see
vital signs

Documentation in
everyday practice

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J.E. Stevenson and G. Nilsson

Table 2 Findings: category, sub-categories and codes

Table 3 Organization of documentation in the EPR

Category

Sub-category

Code

Documentation
in everyday practice

Vital signs
Overview
Medication module

Patient safety
Patient safety
Patient safety

categories from our larger study; the one we report in this

article.

Trustworthiness
Trustworthy is the term applied in qualitative studies to
describe reliability (Polit & Beck 2008). To ensure trustworthiness, two researchers performed the interviews and analysed the data ensuring investigator triangulation (Polit &
Beck 2008). In addition, authentic citations have been
included to increase trustworthiness (Elo & Kyngas 2008).
By this, we believe that a high degree of trustworthiness was
maintained throughout the study. Furthermore, member
checking was carried out by three randomly selected members of the focus groups. They were asked to review and react
to the interview data, emerging categories and results. They
acknowledged that our report gave a true account of what
they perceived. In addition, in October 2009, we presented
our study to a group of 15 nurses, currently using the Cambio
Cosmic EPR in various hospitals in the same region. They
unanimously agreed that what we reported was applicable to
their own experiences.

Journal
Used by all members of the multi-disciplinary team
Care template
Used by nurses only
Report sheet
Used by nurses only

nursing: <2 years (n = 1), 25 years (n = 5), 515 years

(n = 10), >15 years (n = 5). All had been using the current
integrated EPR for 1218 months.
The EPR was used by the entire healthcare team for
documentation. Other professionals such as doctors, physiotherapists and occupational therapists, had one point of
information entry referred to as the journal. Nurses had
three possible locations for documentation; the journal, care
templates and report sheets (Table 3).
Vital signs
As the focus group interviews progressed, it became evident
that there were some issues in determining where various
types of information should be documented. There was no
consensus between different wards, and sometimes within the
same ward, about which part of the EPR was the correct
place for various aspects of nursing documentation.
And its difficult to know whereabouts to write, as there is so much
everywhere. The system allows you to use several different places to
document the same thing, and this is a problem Id say - its not clear
where what should be documented.

Findings

Theres 17 places to document everything... where should I write

what I have found?

Documentation in everyday practice

The evidence for this work comes from the opinions of nurses
using the EPR on a daily basis. The primary focus of this
paper was to describe nurses opinions, directly or indirectly
linked to patient safety aspects of documentation in the EPR
in general wards (Table 2). In the larger study, Documentation in everyday practice emerged as a main category.
There are three sub-categories into which we have grouped
the nurses opinions. The first sub-category is vital signs, and
given priority position as it is generally accepted by nurses as
being vitally important to patient safety. Another subcategory, which emerged from the evidence, was overview.
The third important feature which arose was the medication
module.
The participants were all women and the following
represents age and nursing experience. Age: 2029 years
(n = 4), 3044 years (n = 11), >45 years (n = 6); years in
670

The participants indicated that this could lead to uncertainty

for personnel from another ward.
Its different from ward to ward. If a doctor from a medical ward
comes here on a consultation, they are used to going in to another
part of the EPR to see the blood pressure (BP) and when there is
nothing there, they think we havent taken the patients blood
pressure. But its in the template instead.

Participants reported that they used all three possible

locations for documenting physiological observations. Some
had chosen not to use templates.
There are templates which we should use. Those templates are not so
good as we would like them to be. Therefore, we have chosen not to
use them and write in the report sheet instead.

About half of the nurses (n = 10) indicated that they

thought the correct place to document vital signs such as
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Patient safety in an electronic patient record

temperature, pulse and respiration (TPR) and blood pressure

(BP), was in a care template. Participants described how
creating templates was time-consuming and difficult to learn
with multiple steps and clicks required in the process. A
separate template was required for each observation; one
template for blood pressure, another for pulse, another for
respiratory rate and so on.

This describes how all departments had access to the same

information.
A second advantage was that patient safety was enhanced
because once something was written in the record it was
always there. One example of this is patient allergies.

Some of us have problems to make these templates- it takes a while,

no matter what department the patient is in, and those things are

so if you dont have time, you write in the BP under the heading

safe.

circulation [in the report sheet] so you dont forget it. There are
templates which we should use. There are separate templates for
pulse and blood pressure.
A template entails that you first make an indication and then an
action, so there are many parts, often 3 things must be written before
you can sign it and have your template. And then you write in the BP.
You have to give the reason for taking the blood pressure in the first
place, when you plan to take it and how frequently and how long you
want to do this. And it takes rather many clicks in order to make a
template, it certainly takes 10.

It was also possible to produce a visual graph but this

required further steps and the majority of the participants did
not know how to do this.
Participants described documenting other physiological
values.
Just to record a blood sugar takes a long time. Before, you could add
it to the same chart used for TPR and BP. How many clicks is it? At
least six and probably takes about five minutes.

Nurses reported that this type of patient information had

been charted at the bedside when they had paper charts, but
now they often scrawled information into pocket notebooks
or paper towels until they had time to enter it into the EPR.

Its actually safer. If somethings written down once then its there
forever, such things and warnings and stuff. And it comes up

A third advantage was having less paper to work with.

Everyone was in agreement that they would not like to go
back to paper records; less paper was better.
However, nurses were also anxious to point out disadvantages of the EPR because, they said, no one had given them
the opportunity to air their views before. They reported that
it was difficult to get an overview of patients in the EPR
because of a number of factors and also stated strategies
which they used to ameliorate the problem.
One negative aspect was the time taken in complex
processes thereby taking too much time to find out about
their patients.
The whole process takes longer now; all the clicks to come in and
then you have to choose where to write. We just cant get a picture of
the patients progress.

They described how they searched through many different

sections of the EPR; they scrolled backwards in the report
sheet to read many written notes and those notes made by
doctors on completion of their rounds.
Another difficulty was in finding information, expressed in
the following extract:
An overview is very difficult to get as it takes something like 15 clicks
before you can even begin to understand a little and even then you

Overview
There were both positive and negative opinions reported by
the nurses concerning overview.
It was considered an advantage that nurses could access the
EPR simultaneously allowing many users access at the same
time. Also, time was no longer wasted trying to trace paper
records. This is shown in the following extracts.

may have missed something.

in that way.

Generally, they said that accessing the information they

needed about their patients at their fingertips was an
unnecessarily complex process consuming much time and
risking patient safety if overlooked.
The participants indicated that they had adopted several
strategies to overcome poor accessibility to vital information
in the EPR. Firstly, they reported that they preferred to have a
verbal report to make sure they knew what was important
about their patients.

Everythings there, everyone can read at the same time, and everyone

We just cant get an overview of the patient; therefore, we have gone

can read what everyone has written; there is not that eternal fight

back to verbal reports. I feel safer when I have had a verbal report.

With the computer system, everyone has access the occupational

therapist, physiotherapist, nurses and doctors so its more accessible

over charts.
And the journals are available in every unit, thats really good too.
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Secondly, nurses said they wrote a lot of information in

pocket notebooks. Thirdly, they described the importance of
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J.E. Stevenson and G. Nilsson

using their experience and clinical judgment when meeting

their patients at the beginning of a shift.
We thank our experience for every year that goes... you know what
to focus on.
We depend on our clinical judgment.

A general negative comment was that it was not easy to

change things as they were not involved in the decisionmaking process.
Yes, we all experience that its hard to change things as its so far
away from us the decision-making. And I dont know if they really
perceive just how much of a problem it is for us, if they really
understand.
Its even more annoying to feel that we cant be involved in the

Therefore, nurses were concerned that patients could

inadvertently receive a double dose of a medicine or miss a
dose altogether.
Secondly, adjustments were not accounted for in the
system.
Its not very clear when an adjustment is made in a dose. You cant
see if its newly prescribed.

Thus, it was difficult to see when medications had been

commenced or when doses had been changed.
To sum up, there was general consensus in most of the
views reported. The round robin at the end of each focus
group interview confirmed that none of the nurses wanted to
return to paper records but strongly verified that they wanted
a much improved system.

process and develop this because it is supposed to benefit the patient.

You are the first who have asked us what we think.

Discussion

Medication module
There were mainly positive views from the nurses on the
medication module about patient safety. They reported that
the computer-written text meant that they no longer had
problems with illegible handwriting and could be sure that
they were giving the right medicine in the right dose and this
led to fewer errors. The following opinion from one participant was generally expressed by the group.

Study limitations

You can see which drugs are prescribed and also what colleagues
have written. I think its safer for the patient, much fewer errors.
They get the right medicine in the right dose today.

Another positive view was the advantage of quicker routines

and access to relevant information. It was now possible to
sign for all the medicines at one time when dispensing, which
they valued as it was quicker. They appreciated that it was
very easy to read information about medications because of
the direct link to the Swedish National Formulary (http://
www.fass.se/LIF/home/index.jsp). This led to nurses reading
more about the medicines they administered and improving
knowledge. Some nurses said they felt more secure in that the
medication lists had a direct link to the pharmacy so there
was a degree of internal control.
However, nurses also reported some disadvantages with
the medication module. There were two aspects which they
felt could jeopardize patient safety. Firstly, it was possible to
sign for medications on the wrong day or the wrong time and
nurses said that it was wrong that the system allowed this to
happen.
Its easy to sign something on the wrong day, or the time may not be
correct.
672

We do not claim to make generalizations from the findings in

this study. We have examined the views of a limited number
of nurses (n = 21) and only one electronic record system in
one medium-sized hospital in southeast Sweden. Furthermore, the nurses may have been excessively negative in their
perceptions, as they seemed to need to tell us their concerns
about the system: they reported that no one else had asked
them what they thought about using the EPR. They did not
seem to have any route for their concerns to be taken
seriously and acted upon. Despite these limitations, we feel
that this study adds to research in this field by obtaining
detailed accounts of how these nurses experienced documentation in the EPR. Qualitative design allowed us to probe
deeply into the experience of nurses, obtaining rigorous data
from the sharp end of patient care.
The findings give a deeper insight into nurses perceptions
of using the EPR in general wards. The evidence presented
supports the international literature which suggests problems
with poor navigability and in obtaining an overview of the
patient (Darbyshire 2000, 2003, Timmons 2003, Moody
et al. 2004, Smith et al. 2005). Furthermore, the evidence
suggests that these issues could have a bearing on patient
safety, in line with Stevenson et al. (2010).
It is apparent from the findings presented that there were
difficulties encountered in documenting vital signs, also
recognized by Moody et al. (2004). The importance of easy
access to vital signs is underlined by current trends for
hospitals in the UK to use track and trigger systems such as
Early Warning Scores (EWS) systems (Department of Health
2007). These systems were created to detect early signs and
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JAN: SHORT REPORT

What is already known about this topic

Nurses play a pivotal role in patient safety.
Although nurses recognize benefits with electronic
patient records, there is general dissatisfaction with the
systems.
Electronic patient records take more time for
documentation.

What this paper adds

Essential information such as vital sign recordings of
temperature, pulse and respiratory rate, and blood
pressure is difficult to enter and locate in the electronic
patient record.
Nursing documentation is disseminated throughout the
electronic patient record; it is unclear where specific
information should be documented.
Nurses adapt their routines to maintain patient safety
by working around the system.

Implications for practice and/or policy

Patient safety could be threatened if vital information
on physiological status is not easily accessible.
Careful monitoring of documentation should be
maintained during the implementation of electronic
patient record systems.
The opinions of end-users need to be taken into account
in system design so that systems meet the demands of
working practice and patient safety.

secure timely rescue of the deteriorating patient. Further, they

facilitate the early recognition of deteriorating patients at the
earliest possible stage, thereby reducing the incidence of
cardiac arrest and unplanned admission to intensive care
units (Buist et al. 2002, Andrews & Waterman 2005,
McBride et al. 2005, Gardner-Thorpe et al. 2006).
In line with other international studies (Darbyshire 2000,
2003, Timmons 2003, Moody et al. 2004, Smith et al.
2005), vital information was difficult to enter and difficult to
view in the EPR, because the system was cumbersome and
complicated to navigate, Moreover, it was not easy to enter
or find patient information because there was not a designated area for documenting various patient data, for
example, vital signs. This could mean that the nurses role
in maintaining high-quality patient vigilance may be difficult
to realize in this EPR; clinicians may need to view several
locations to find vital sign recordings; trends deviating from
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Patient safety in an electronic patient record

the norm could be overlooked and signs of patient deterioration missed. To be effective, this essential information
ought to be grouped in a way that allows trends to be easily
viewed, giving accurate indication of patient status (Hutson
& Millar 2009). Information that is hard to locate could be
especially problematic for nurses at the beginning of a new
shift. Despins et al. (2009) recognized that procedures which
fully communicate patient status will more easily distinguish
patients who are at risk. In light of age-old practice, and in
current trends to try to ensure early detection of patient
deterioration, EPRs which support good documentation
routines are essential.
The findings support the literature which suggests that a
problem of EPR is lack of overview (Darbyshire 2000, Rose
et al. 2005, Smith et al. 2005). The participants experienced
that this had two main effects. Firstly, excessive time spent
trying to find information could imply less time for hands-on
patient care and thereby, patient safety could be put at risk.
Even if each piece of data retrieval only takes some minutes
longer than previously, the accumulative result could have an
important impact on time available for hands-on patient care.
Secondly, difficulty in identifying the most important information, left nurses feeling insecure as they were afraid they
might miss something. To feel unsafe could suggest that the
patients safety was threatened because nurses did not have
relevant information at their fingertips. In this context, it is
logical to believe that less time spent with the patient could
incur additional strain on clinicians which could increase the
risk of dangerous errors (Peute et al. 2008). Poor design can
even put heavy demands on users mental energy (Rose et al.
2005) and this overload in turn may lead to an adverse effect
on performance and judgment, according to high reliability
theory (Despins et al. 2009).
Nurses appreciated the benefits of the medication module,
but also suggested there could be problems. Improved
legibility of text rather than handwriting was an advantage
consistent with the literature (Smith et al. 2005). However,
being able to sign for medicines on the wrong date or time
during administration, raised concerns for patient safety as
this meant that it could look as though a patient had not had
their medication when in fact they had. One possible
outcome of this is therefore the risk of a patient receiving a
double dose or missing a dose. As medication errors are a
major cause of medical error (IOM 2000, Nielsen 2005), the
threat to patient safety is evident. According to the IOM
(2000), to prevent error and improve safety for patients,
conditions that contribute to errors should be modified,
indicating the need for modification here. Further, other
studies underline the importance of safety in design, as poorly
designed systems may have the unintentional potential of
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J.E. Stevenson and G. Nilsson

increasing medical errors (Kushniruk et al. 2004, Wong et al.

2008).
Previous studies emphasize the important role nurses
perform in maintaining patient safety; vigilance is high on
the priority list. In its landmark report To err is human, the
Institute of Medicine commented that nursing vigilance
protects patients against error (IOM 2000). In addition,
quality of nursing has an important impact on patient safety
(Burhans 2010). The evidence in our study suggests that
nurses strove to maintain a culture of patient safety. As
described by Feng et al. (2008), patient safety culture is the
observable degree of effort with which all members in the
organization direct their attention and actions towards
improving patient safety on a daily basis. These nurses
seemed to make a considerable effort to find ways to ensure
patient safety. For example, they had more verbal reports and
wrote notes to keep in their pockets. Another strategy was
that the nurses used their clinical judgment and experience to
get a picture of their patients, for instance, at the beginning of
a shift as they went round and met their patients. It is
unfortunate that nurses felt obliged to work around the EPR
system but this finding is also supported in other studies
(Timmons 2003, Rose et al. 2005).

Conclusion
The accounts presented in this paper make an important
contribution to knowledge about nurses perceptions of EPR.
Although this study may appear, superficially, as a list of
complaints by discontented end-users, it does identify what
works well and not so well in the EPR. Most importantly, it
identifies factors in the system which enhance patient safety,
and the factors which put patient safety at risk, an aspect we
have not found in other studies. For this reason, our study
emphasizes the need for systems to support documentation
related to patient vigilance and, thus, patient safety. In a
climate of rising awareness of hospital-induced patient safety
incidents, the need for accurate record keeping has never been
greater (EU 2005, RCN 2008). As proposed by other studies
(Goorman & Berg 2000, Berg 2001, Nemeth et al. 2005,
Rose et al. 2005, Clark 2007), we also recommend that
designers listen to the views of end-users to understand work
routines and workflow, and subsequently design optimal
systems. More research is required in this field, especially
qualitative studies as indicated by Berg (2001).
Moreover, close monitoring of systems during implementation could enhance usability (Berg 2001, Kushniruk 2002).
This might avoid convoluted decision-making procedures
when modification is required. Finally, we recommend that
organizations have a policy for reviewing EPR systems prior
674

to implementation to ensure they facilitate patient safety and

meet the needs of the end-users (Carrajo et al. 2008, Peute
et al. 2008).

Acknowledgements
The authors offer their sincere thanks to the nurses who
kindly shared their experiences and made this study possible.
We are also grateful to those who helped to arrange time and
place for the interviews and to the hospital managers who
allowed us to conduct the study. Further, we extend our
gratitude to Professor Catherine Legrand and Dr Rowena
Jansson for reviewing the manuscript. This study was
supported by Linnaeus University, Kalmar, Sweden.

Funding
This research received no specific grant from any funding
agency in the public, commercial, or not-for-profit sectors.

Author contributions
JS was responsible for the study conception and design. JS
and GN performed the data collection. JS and GN performed
the data analysis. JS was responsible for the drafting of the
manuscript. JS and GN made critical revisions to the paper
for important intellectual content. GN supervised the study.

References
Andrews T. & Waterman H. (2005) Packaging: a grounded theory of
how to report physiological deterioration effectively. Journal of
Advanced Nursing 52(5), 473481.
Armitage M., Eddleston J. & Stokes T. (2007) Recognising and
responding to acute illness in adults in hospital: summary of NICE
guidance. BMJ 335(7613), 258259.
Berg M. (2001) Implementing information systems in health care
organizations: myths and challenges. International Journal of
Medical Informatics 64(23), 143156.
Buist M.D., Moore G.E., Bernard S.A., Waxman B.P., Anderson J.N.
& Nguyen T.V. (2002) Effects of a medical emergency team on
reduction of incidence of and mortality from unexpected cardiac
arrests in hospital: preliminary study. BMJ 324(7334), 387390.
Burhans L. & Alligood M. (2010) Quality nursing in the words of
nurses. Journal of Advanced Nursing 66(8), 16891697.
Carrajo L., Penas A., Melcon R., Gonzalez F. & Couto E. (2008)
From documents on paper to electronic medical records. In The
XXIst International Congress of the European Federation for
Medical Informatics eHealth Beyond the Horizon Get IT There
(Andersen S.K., Klein G.O., Schulz S. & Aarts J., eds), IOS Press,
Sweden, pp. 395401.
Clark J. (2007) The Impact of ICT on health, healthcare and nursing
in the next 20 Years. Studies in Health Technology and Informatics
128, 95114.
 2011 The Authors
Journal of Advanced Nursing  2011 Blackwell Publishing Ltd

JAN: SHORT REPORT

Clarke S. & Aiken L. (2005) More nursing, fewer deaths. Quality
and Safety in Health Care 15(1), 23.
Darbyshire P. (2000) User-friendliness of computerized information
systems. Computers in Nursing 18(2), 9399.
Darbyshire P. (2003) Rage against the machine?: nurses and midwives experiences of using Computerized Patient Information
Systems for clinical information. Journal of Clinical Nursing 13,
1725.
Department of Health (2008) High quality care for all: NHS Next
Stage Review final report. Department of Health, The Stationary
Office, London.
Despins L., Scott-Cawiezell J. & Rouder N. (2009) Detection of
patient risk by nurses: a theoretical framework. Journal of
Advanced Nursing 66(2), 465474.
Department of Health (2007) Acute medical care. The right person,
in the right setting first time. pp. 2232.
Elo S. & Kyngas H. (2008) The qualitative content analysis process.
Journal of Advanced Nursing 62(1), 107115.
EU (2005) Patient Safety Making it Happen! Luxembourg Declaration on Patient Safety. (Protection E. C. D. H. a. C. ed),
Luxembourg.
Feng X., Bobay K. & Weiss M. (2008) Patient safey culture in
nursing: a dimensional concept analyis. Journal of Advanced
Nursing 63(3), 310319.
Gardner-Thorpe J., Love N., Wrightson J., Walsh S. & Keeling N.
(2006) The value of Modified Early Warning Score (MEWS) in
surgical in-patients: a prospective observational study. Annals of
the Royal College of Surgeons of England 88(6), 571575.
Goorman E. & Berg M. (2000) Modelling nursing activities: electronic patient records and their discontents. Nursing Inquiry 7(1),
39.
Graneheim U.H. & Lundman B. (2004) Qualitative content analysis
in nursing research: concepts, procedures and measures to achieve
trustworthiness. Nurse Education Today 24, 105112.
Granlien M.F., Hertzum M. & Gudmundsen J. (2008) The gap
between actual and mandated use of an electronic medication record
three years after deployment. In The XXIst International Congress
of the European Federation for Medical Informatics eHealth Beyond
the Horizon - Get IT There (Andersen S.K., Klein G.O., Schulz S &
Aarts J., eds), IOS Press, Gothenburg, pp. 419424.
Hillman K., Parr M., Flabouris A., Bishop G. & Stewart A. (2001)
Redefining in-hospital resuscitation: the concept of the medical
emergency team. Resuscitation 48(2), 105110.
Hutson M. & Millar E. (2009) Record keeping. In Clinical Skills: The
Essence Of Caring (Iggulden H., MacDonald C. & Staniland K.,
eds), McGraw Hill, Open University Press, London, pp. 2751.
IOM (2000) To Err is Human: Building a Safer Health System.
Institute of Medicine, Washington, DC.
IOM (2004) Keeping Patients Safe: Transforming the Work Environment of Nurses. Institute of Medicine, Washington, DC.
James J., Butler-Williams C., Hunt J. & Cox H. (2010) Vital signs for
vital people: an exploratory study into the role of the Healthcare
Assistant in recognising, recording and responding to the acutely ill
patient in the general ward setting. Journal of Nursing Management 18(5), 548555.
Kushniruk A. (2002) Evaluation in the design of health information
systems: application of approaches emerging from usability engineering. Computers in Biology and Medicine 32(3), 141149.
 2011 The Authors
Journal of Advanced Nursing  2011 Blackwell Publishing Ltd

Patient safety in an electronic patient record

Kushniruk A., Triola M., Stein B., Borycki E. & Kannry J. (2004)
The relationship of usability to medical error: an evaluation of
errors associated with usability problems in the use of a handheld
application for prescribing medications. In International Medical
Informatics Conference (Fieschi M., Coiera E. & Li Y., eds), IOS
Press, Amsterdam, pp. 10731076.
Lind T. (2007) End-users Experience of the Impact of the Implementation of Cambio Cosmic (an EPR) in 4 Hospital Wards in
Varmland County Council, Sweden (author translation).
[In Swedish: Anvandarnas erfarenhet av Cambio Cosmic under
inforandet pa 4 kliniker i Landstinget i Varmland]. Varmland
County Council, Karlstad.
McBride J., Knight D., Piper J. & Smith G. (2005) Long term effect
of introducing an early warning score on respiratory charting in
general wards. Resuscitation 65, 4144.
McLafferty I. (2004) Methodological issues in nursing research: focus
group interviews as a data collection strategy. Journal of Advanced
Nursing 48(2), 187.
Moody L.E., Slocumb E., Berg B. & Jackson D. (2004) Electronic
health records documentation in nursing nurses perceptions,
attitudes, and preferences. Cin-Computers Informatics Nursing
22(6), 337344.
Nemeth C., Nunnally M., OConnor M., Klock P.A. & Cook R.
(2005) Getting to the point: developing IT for the sharp end of
healthcare. Journal of Biomedical Informatics 38(1), 1825.
NICE (2007) NICE Clinical Guideline 50 Acutely Ill Patients in
Hospital: Recognition of and Response to Acute Illness in Adults
in Hospital, Vol. 2009. National Institute for Health and Clinical
Excellence, London.
Nielsen J. (2005) Medical usability: how to kill patients through bad
design. Retrieved from http://www.useit.com/alertbox/20050411.
html on 4 July 2011.
Peute L.W., Spithoven R., Bakker P.J. & Jaspers M.W. (2008)
Usability studies on interactive health information systems; where
do we stand? Studies in Health Technology and Informatics 136,
327332.
Polit D.F. & Beck C.T. (2008) Nursing Research: Generating and
Assessing Evidence for Nursing Practice. Lippincott Williams &
Wilkins, Philadelphia.
Royal College of Nursing (2008) Nursing content of electronic
patient/client records. In RCN e-Health Programme. Policy statement. RCN, London.
Rose A.F., Schnipper J.L., Park E.R., Poon E.G., Li Q. & Middleton
B. (2005) Using qualitative studies to improve the usability of an
EMR. Journal of Biomedical Informatics 38(1), 5160.
Smith K., Smith V., Krugman M. & Oman K. (2005) Evaluating the
impact of computerized clinical documentation. Computers
Informatics Nursing 23(3), 132138.
Stevenson J.E., Nilsson G.C., Petersson G.I. & Johansson P.E. (2010)
Nurses experience of using electronic patient records in everyday
practice in acute/in-patient ward settings: a literature review.
Health Informatics Journal 16(1), 6372.
Timmons S. (2003) Nurses resisting information technology. Nursing
Inquiry 10(4), 257269.
Wong M.C., Turner P. & Yee K.C. (2008) Involving clinicians in the
development of an electronic clinical handover system thinking
systems not just technology. Studies in Health Technology and
Informatics 136, 490495.

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