Medication administration records play an important role in patient safety, continuity of care and professional accountability. Hospitals are increasingly replacing paper charts with electronic systems that support prescribing, dispensing, administration records and medication reconciliation. A stepped-wedge cluster randomised trial published in BMJ Health & Care Informatics compared paper medication charts with an electronic medication management system in a tertiary paediatric hospital in Sydney, Australia. The comparison focused on whether documentation became more complete, more accurate and more legally compliant after the electronic system was introduced. The findings show a mixed picture. Electronic records reduced some documentation gaps and helped prevent administration from problematic prescriptions, but they also introduced new risks when recorded details did not match what nurses actually did during medication administration.
Observed Practice During System Rollout
The electronic medication management system was introduced across nine general wards over several weeks. At the beginning, all wards used paper charts. Each ward then moved to the electronic system in turn until all wards were using it. The system supported electronic prescribing, documentation of dispensing and administration, medication reconciliation and monitoring. It also included functions intended to support safer and more efficient prescribing and administration, such as standardised order options, dose support, allergy checking and interaction checking.
Medication administration was assessed through direct observation. Trained nurse observers followed consenting nurses during routine care and recorded details of each administration using a structured data collection tool. The recorded details included whether the administration was signed for, the timing of signing and administration, preparation steps and administration method.
After observation, the recorded practice was compared with the medication record. The comparison identified documentation and legal errors, including missing signatures, missing administration times, inaccurate recorded details, conflicting instructions and administration based on an incorrect, illegal or incomplete prescription. Wrong-drug administrations were excluded from this part of the analysis because other documentation errors were not assessed for administrations that should not have occurred.
Improved Completeness but Reduced Accuracy
The final analysis included more than 5,000 medication administrations involving paediatric patients and nurses across the participating wards. Most administrations were documented correctly overall, and almost all records included both a signature and an administration time. The use of electronic medication management did not significantly change the proportion of administrations without a nurse signature.
The clearest improvement concerned missing administration times. Electronic records were much less likely than paper charts to have no administration time documented. This suggests that electronic systems can support more complete recording of basic administration information, particularly when required fields or workflow prompts make omissions less likely.
The electronic system was also associated with fewer administrations from incorrect, illegal or incomplete prescriptions. This points to one of the intended benefits of electronic medication management: better support for safer medication processes at the point where prescriptions are written, checked and used.
However, documentation accuracy worsened in another important area. Recorded administration details were more likely to differ from what observers saw when the electronic system was used. Examples included mismatches between the recorded and observed method of intravenous administration. Incorrect details appeared in a noticeably higher proportion of electronic records than paper records. The findings therefore separate completeness from accuracy: an electronic record may contain more required fields while still failing to reflect the administration process correctly.
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Workflow and Autopopulated Fields
Timing patterns showed a broader workflow issue across both paper and electronic records. Nurses often signed the medication chart before giving the medicine. In many cases, signing happened shortly before administration, suggesting that this sequence had become part of routine workflow. However, signing before administration increases the risk that the record does not accurately reflect what happened if the administration changes, is delayed or is not completed as expected.
The documented administration time was most often close to the observed administration time, but the record frequently showed an earlier time. This happened with both paper and electronic records and was more common after electronic medication management was introduced. Paper charts were more likely than electronic records to show a time documented later than the observed administration.
Some inaccuracies may relate to how electronic systems handle prefilled information. Autopopulated fields can reduce manual work, but they depend on users checking and correcting details before signing. If the system carries forward information from the prescription into the administration record, an incorrect or unsuitable instruction can also appear in the final documentation.
Conflicting instructions increased after electronic medication management was introduced. One example involved differences between a prescribed intravenous method and ancillary information in the system. In practice, nurses may have administered the medicine using the appropriate method while the record retained another instruction. The comparison does not establish every mechanism behind these mismatches, but it shows that electronic workflow design, prescriber selections and administration documentation can interact in ways that affect record accuracy.
Electronic medication management improved parts of medication administration documentation in a paediatric hospital, especially the recording of administration times and the avoidance of administration from problematic prescriptions. At the same time, recorded administration details were more often inaccurate after the electronic system was introduced. The findings show that implementation support, staff training and system configuration matter when hospitals move from paper charts to electronic medication records. Mature systems need to make accurate documentation practical within routine nursing workflow, not only more complete on screen.
Source: BMJ Health & Care Informatics
Image Credit: iStock
References:
Badgery-Parker T, Li L, Woods A et al. (2026) Does the accuracy of medication administration documentation improve with electronic medication systems? A stepped-wedge cluster randomised trial. BMJ Health & Care Informatics;33:e101507.
