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Electronic patient records (EPR) can contribute to risks of patient care being missed, delayed or incorrect, according to results of an investigation by the Health Services Safety Investigations Body (HSSIB).
In a review of 63 HSSIB investigation reports associated with EPR systems from 2018 to 2025, published on 27 November 2025, the watchdog found that patient safety risks were “persistent despite national recommendations and actions seeking to mitigate them”.
The report cited an example of a young female patient, aged four years, who was prescribed an incorrect dose of blood-thinning medication.
The patient’s weight meant she required 1,520 units twice daily; however, the medication was inadvertently prescribed at a dose of 15,000 units twice daily via the use of an electronic prescribing and medicines administration (ePMA) system.
“The ePMA system did not identify the incorrect prescription. The patient received five doses of the medication over three days, and this contributed to bleeding around her brain,” the report said.
EPR systems are software for collecting, storing and managing data about individual patients, which are used across the NHS.
However, the report found that the configuration of the ePMA system encouraged the selection of preferred strengths of the medication for adults.
“The prescriber selected an adult strength of the medication from a ‘quick list’. The system then relied on the doctor manually entering the correct dose, replacing the dose information that had been automatically entered by the system,” it added.
“This was not done correctly and functionality had not been configured to support safe prescribing of this medication to children.”
The report also found that EPR systems contributed to other patient safety incidents in cases where they lacked functions an organisation needed and that there were inconsistencies in the terms used in systems, along with limited guidance on understanding these.
It said that variation in governance processes for implementing EPR systems meant associated patient safety risks were not always identified and mitigated, while the implementation of systems did not always engage users to ensure it was successful.
The HSSIB also highlighted that in investigations, staff reported limited routes for raising concerns about poor functionality and that EPR systems were not always kept up to date in line with national guidance and standards, or to reflect changes in internal care processes.
As a result, it recommended: “National bodies responsible for providing digital advice and guidance to NHS organisations can improve patient safety by clarifying consistent definitions for design-related IT terms — such as usability and functionality — and sharing guidance on how to apply design principles to EPR system configuration and optimisation.”
Rachel Power, chief executive of the Patients Association, commented: “We are deeply concerned that poorly implemented EPR systems are directly contributing to patient safety issues. When these systems fail, the consequences are very serious, as patients face delayed diagnoses, medication errors and missed care.
“Staff are warning about the risk, yet their concerns seem to be going unheard. National leaders must move beyond issuing more guidance and act now to ensure EPR systems are safe, tested and support joined-up patient care.”
In response to the report, a spokesperson for NHS England said: “EPR systems are a huge step forward from the outdated, often paper-based systems they are replacing. They play an important role in improving the safety and quality of care delivered to patients, including helping to detect conditions such as sepsis.
“Their implementation is part of the digital by default approach to make the NHS safer and more efficient. We are working closely with NHS trusts to support them with EPRs, including staff training to ensure they are used and operated to the highest quality and safety standards.
“We have well-established systems in place for reporting, investigating and learning from any patient safety incident — but we will take on board the issues raised by the HSSIB and look at further actions that should be taken,” they added.
