Use it or lose it: The role user unfamiliarity with electronic medication systems plays in medication errors


  • Madaline Kinlay The University of Sydney
  • Melissa Baysari The University of Sydney
  • Wu Yi Zheng Black Dog Institute
  • Ilona Juraskova The University of Sydney
  • Rosemary Burke Sydney Local Health District
  • Lai Mun Ho Sydney Local Health District
  • Hannah Turton Sydney Local Health District
  • Jason Trinh Sydney Local Health District


Background: Electronic medication management systems (EMMS) improve medication safety, but simultaneously introduce new system-related errors, errors highly unlikely with the use of paper records. No research has examined how these errors change over time and whether errors related to user unfamiliarity with EMMS decrease over time.

Aims: To explore how incident reports of system-related errors related to user unfamiliarity with EMMS change over time.

Methods: EMMS-related incidents occurring at three hospitals in a Local Health District between 1 January 2010 and 31 December 2019 were extracted from the NSW Health Incident Information Management System. Each hospital had introduced the EMMS at different time points (one, three and 12 years prior). Factors contributing to these EMMS-related incidents were extracted and classified, including user ‘misunderstanding or unfamiliarity with EMMS or EMMS workflow’ and ‘inadequate training or education’.

Results: The number of incident reports related to user unfamiliarity or inadequate training fluctuated over time but never dissipated. User unfamiliarity and inadequate training were associated with at least 8 incidents every year (range 8 – 55 incidents) and were still contributing factors to reported incidents in the hospital that had had EMMS in place for over 12 years.

Conclusions: EMMS become more embedded in hospitals with long-term use, but our results indicate that user unfamiliarity with the system is an ongoing issue, despite long-term use. This result highlights that EMMS are not set-and-forget systems. Organisations are required to provide ongoing training for new/rotating staff and refresher training with the addition of new functionality to systems.