What is the effectiveness of electronic interventions including electronic prescribing systems, barcode medication administration (BCMA), and pharmacist-led IT tools in reducing medication errors in NHS settings in England?

ABSTRACT (IMRAD)

Introduction- The medication process present with the paper based prescription system faced significant threats in relation to the patient’s safety and hence the current research evaluated the effectiveness of eprescription system with the relevance of PINCER and BCMA.  The aim of the research is ‘’ how patient safety is impacted by technology usage and how it reduces the adversity of prescription drugs, using electronic prescribing system at institutional level.’’

Methods- It used PRISMA to filter research journal articles from (CINAHL, MEDLINE, APA PsycINFO, Dementia journal, Gerontology, and Cochrane) and five articles were chosen. It is a secondary research that helped to capture prevalent practices on research phenomenon in real life, and synthesize its outcomes to gain insights using thematic analysis.

Results- Results showed BCMA achieving 100% patient satisfaction in surgical settings and PINCER interventions to reduce hazardous prescription workflow methods and processes thereby significantly urging the nursing fraternity to be compliant in a techno social environment that is high water pressure requiring 100% patient safety.

Analysis- It is evident that the success of E prescription system is an institutional demand that is dependent upon different IT systems and a higher system of clinical decision support platform that synthesizes real time data in creating alerts and adding human decisions for overcoming the socio-technical barriers and help nurses for workarounds

Discussion- It can be concluded that electronic interventions in a healthcare system are able to significantly reduce the drug adversity drug dosage mismatch chances enhancing patient safety and yet the benefits can erode overtime, if the practices from nursing perspective is not meeting the continuous learning process and compliance adherence.

Key words:  PINCER, BCMA, eprescription, nursing, healthcare

Chapter One

1.INTRODUCTION

In the health institutions, designing a healthcare system comprises of the patients nurses, doctors, and IT system which is able to ease clinical operations and its management efficiently and effectively. However, any system has dimension of errors or defects, that cause extended period of patient stay, harm to the patient, and adding on to the financial burdens (Clifford,  2025). In the context of UK, the NHS ‘National Health Service’ has protocol based medication administering practices, which is aligned with the doctor prescribing, and the medication dispensing, that has adopted electronic interventions for patients linking the pharmaceutical supply chain (Colin et al. 2025). The concept of BCMA or ‘bar code medication administration’ has emerged strongly in last decade, thereby, facilitating the electronic prescribing systems impacting the hospital as organisation, the doctor, the patient, nurses, impacting the paper prescription process to be digitalized (Williams et al. 2022). The implication of the above, has led to aspects of drug matching as per patient diagnosis, and also the pharmacy leading to close the gaps of human errors, matching records, decision making and oversight. Eprescription system however, offers a digitalised environment of records, involving multiple technologies for a 100% clinical decision support system. However, research studies show that technologies are designed, to eliminate human error, workflow efficiency to enhance the patient safety, have been compromised, challenged in terms of the practical and real-life incidents (Wissal, 2025).  The vital question remains about the resource constraint, staff training, and systems integration, for barcode medication administration across institutions (hospitals and pharmacies), that exposes the gap illustrated in the literature review secondary research (Shiima et al. 2022). The critical insight about the limitations and the impact, thereby, contributing towards the current research topic. This raises the central question: What is the effectiveness of electronic interventions including electronic prescribing systems, barcode medication administration (BCMA), and pharmacist-led IT tools in reducing medication errors in NHS settings in England?”‘

1.1. BACKGROUND AND SIGNIFICANCE

1.1.1. Aim of the Literature Review

A literature review contributes to diverse dimensions of the research phenomenon to understand the research topic deeply (Aveyard & Bradbury-Jones, 2019).  The literature review in any research, helps to establish the past findings in relation to the research phenomenon and thereby, demonstrate the dimensions (Holloway & Galvin, 2023). The current research shows how patient safety is impacted by technology usage and how it reduces the adversity of prescription drugs, using electronic prescribing system at institutional level.

1.1.2 Electronic prescribing system

The electronic prescribing systems are designed to replace the age-old handwritten doctor prescriptions for the patients, thereby, reducing the human transcription errors (Goodman & Miller, 2021). Understanding the system characteristics and the ability to reduce the medication errors or defects in prescribing system (Adeyemi et al. 2024) is critical, as it helps to measure ensure the pathway of improvement process, in electronic communication formats (Elshayib  & Pawola, 2020). The communication modalities between the pharmacist and the drug prescriber, defines failsafe pathway (Strauven et al. 2020), that impacts the institutional workforce efficiency, impacting the quality dimension in patient care safety (Cahill et al. 2025) and patient satisfaction outcomes (Farre et al. 2019). While the manual prescribing practice had illegibility in the prescription, incomplete information, the structure and process centric electronic prescribing system is also facing the challenges (Tantray et al. 2024), that of ‘system downtime’, the ‘user resistance’ recurring continuous training to show its adoption and prevalence in healthcare institutions (Penati, 2024).

1.1.3 Barcode medication administration system

The second dimension is ‘barcode medication administration system’ which ensures how the right patient, with the right medication, with the right dose and on-time dosage administration, has led to intelligent prescription system (Owens et al. 2020) (Zheng et al,.2021) offering nursing autonomy (Hong et al. 2021). In this context, the patient perception about the medication, the packaging have embedded scanning barcodes along with the prescription offers cost-effort-time savings, which is the literature review shows automation in eprescription as evidence (Jessurun et al. 2021). However, in order to remove the administration error reduction, a standard compliance based process and improving outcome in the medical environment requires guidelines (van der Veen et al. 2020).

1.1.4. Why Is This Important in Nursing?

Between the patient, nurse and doctor relationship, the institutional role to safeguard medication safety for the patient satisfaction involves multiple stakeholders (Shapovalov, 2023), like the pharmacy and nurses, that forms the last and final checkpoint before the drug administration process happens (Ahmed & Tamim, 2025). Any error act any stage have serious impact on the patient treatment outcomes (Nurmeksela et al. 2021), which directly points to the healthcare institution professional accountability (Bhati et al. 2023). Therefore, the BAMS is an electronic intervention in the hospital operations management environment, where  pharmacist led IT as e-tool, that aligns with multiple stakeholders in the institution, is reducing the clinician cognitive load, standardizing workprocesses and streamlining the process of eprescription communication in the digital format (Mohiuddin, 2019) impacting patient-provider improvement in healthcare (Drossman, & Ruddy, 2020). This offers a real-time safeguard to the patients against the human mistakes (Vaismoradi et al. 2020). The effectiveness is crucial for safeguarding the patient safety upholding the ethics of nursing practice, physician practices, adopting integrated IT system, for seamless communication offering autonomy in decision making, building brand credibility of the healthcare institution (Molina-Mula & Gallo-Estrada, 2020). Therefore, the current research contributes to understanding the tools which help the nurses and the evolution of the healthcare technology that strengthens the process given approach in providing safe high quality healthcare to the patients.

1.2 DEFINITIONS

To conduct a thorough analysis, it is essential to clearly define key terms.

1.2.1. BCMA

This is defined as a technology which uses barcode and specifically used in medical sector, with drug, dose, dosage implementation to right patient at right time.

1.2.2. e-prescribing

The process through which the doctor uses a digital platform in order to recommend the prescribed drugs for the patient treatment outcomes. It reduces the aspect of hand written prescriptions, reducing probability of errors, stolen/lost, legibility issues.

1.2.3. CDS

Clinical decision support

This uses the IT based platform to give the clinicians electronic format of output, guiding them with alerts, reminder to nurses and/or patients offering transparent evidence based guidance.

Chapter 2 (Methodology)

The research methodology section gives a justification of the steps to be followed to find relevant literature, to answer the research question and achieve the research objectives (Snyder, 2019). The literature review that is based on a systematic research approach entails the development of a purposeful research question, systematic manner of searching right articles, appraising each one by one (Pollock & Berge, 2018), and then finally evaluating the published results. Although Bramer et al. (2018) argued that a quality literature review uses a systematic method while searching and analysing the literature, it might not be considered as a thorough as a systematic review.

Developing the review question:

Coming up with a review question is the initial step in a literature review (Rodgers & Yee, 2023) is a first step towards understanding. The purpose of this review is to answer ‘’ What is the effectiveness of electronic interventions including electronic prescribing systems, barcode medication administration (BCMA), and pharmacist-led IT tools in reducing medication errors in NHS settings in England?’. In order to formulate a clear focused question depending on the above chosen topic, the tools PICO (Population, Intervention, Comparison, and Outcome) (Kloda et al. 2020), and SPIDER uses (sample, phenomenon of the interest in researcher, design, evaluation, and research type) which is predominantly for qualitative and mixed research (van der Waldt, 2025). Even though PICO is an effective tool in the development of research questions, it is specific to quantitative studies. Thus, SPIDER was applied, which is intended to be applied in qualitative research in table 1, but Cooke, Smith, & Booth,  (2012) argued that SPIDER tool can fail to identify the relevant papers during literature searching because it is specific.

Qualitative approach:

The qualitative research approach was used in order to respond to the question, ‘’ What is the effectiveness of electronic interventions including electronic prescribing systems, barcode medication administration (BCMA), and pharmacist-led IT tools in reducing medication errors in NHS settings in England?’’  Bettany-Saltikov & McSherry, (2024) and (Polanin et al. 2019) highlight that the structure of a literature review must be closely consistent with the questions which were asked during the review. Qualitative research will seek to investigate the phenomena of humans that give detailed descriptions and theoretical elaborations (Bazen, Barg & Takeshita, 2021). This method puts depth at the forefront, with the views of the participants being the centre of attention (Lim, 2025). Although it has been criticized that qualitative literature reviews might not be systematic,

Table 1: Formulation of the research question

resulting in less reliable evidence being obtained by chance and not by rigorous methods (Oranga & Matere, 2023) emphasize that rigour, sometimes known as trustworthiness, can be obtained through transparency and by reporting the systematic process followed

Search strategy:

A systematic search is used to identify the research study variables which describe its overall research phenomenon, which is relevant to the review question (MacFarlane, Russell-Rose, & Shokraneh, 2022). It included searching by keywords that are embedded in the topic, and a combination of variables, that correspond to the review question.

Table 2:  Keywords

This helped the researcher to make sure that the output of selected literature is exhaustive, avoids selectivity or a tendency to cherry-pick research studies (Harari et al. 2020). The Boolean operators and truncation (asterisk,) were used together with the research keywords, to find the required literature (Salvador-Oliván, Marco-Cuenca, & Arquero-Avilés, 2019). Preliminary scoping search was conducted to evaluate the presence of qualitative literature on the selected topic with the help of such keywords as – electronic interventions, electronic prescribing system, barcode medication administration (BCMA), pharmacist-led IT tools, in combination with phrases like reducing medication errors, NHS. Although this search produced a few indirectly relevant literature, new keywords were found, including by permutation and combination of words-phrases, that was included in the search procedure (see Table 2), which helped to find more relevant literature. Maltseva, & Batagelj, (2020) suggest using the keywords identified to include various representations of the topic of the review. Search concepts were effectively combined using Boolean operators “AND” and “OR” (Grames et al. 2019), and a search concept was broadened with the use of truncation (Sivakumar, & Sivakumar, 2025)) although with a risk of retrieving irrelevant articles.

Database searched:

In order to maintain its focus and select the unbiased literature review, bibliographic databases were used. The general search engines available in the market such as Google, Yahoo, which may provide an abundance of varied information output can be unreliable. The databases which were deployed in this research like – MEDLINE, PsycINFO, CINAHL, APA and Academic search complete was preferred due to their capability in producing subject area specific articles (Gusenbauer & Haddaway, 2020).

CINAHL offers diverse nursing literature, and is a searching tool in that domain, that can successfully locate qualitative research. It offers useful research articles in the context of UK even with North American bias the output are credible (Hopia & Heikkilä, 2020). On the other hand, the MEDLINE search offers diverse medical and nursing information. Similarly, the APA PsycINFO provides access peer-reviewed journals around to 98% are specifically on psychological care in nursing area (Sirois, & Owens, 2021). Academic search is complete therefore, is a multidisciplinary database, which expands the range of available scholarly articles. Limiters were used to narrow the search to only English language publications published in the past 2015-2025, which could potentially filter out some potential studies of interest.

Inclusion and Exclusion criteria:

To achieve a systematic search strategy, it is important to have clear inclusion and exclusion criteria (see Table 3) in order to select only those studies that are directly related to the review question (Krnic Martinic et al. 2019).In this instance the studies that were prioritised were the ones that

Table 3: Xyz

examine the experiences of nurses in relation to the ‘electronic prescribing systems, barcode medication administration (BCMA), and pharmacist-led IT tools’ in NHS England. Cochrane systematic reviews are believed to be the gold standard; however, they lacked inclusion because their focus was on healthcare interventions, which are not the focus of this review (Moore, Fisher, & Eccleston, 2022). Rather, qualitative research by peers was selected due to its credibility and high-quality assessment. Non-UK studies were filtered out to prevent the occurrence of discrepancies due to differences in healthcare systems to make them relevant to UK nursing practice. Even though, it is possible to learn much on the basis of their experience of other countries, and the specified aspect remains underdeveloped in other countries in particular to cite in this research. These criteria narrowed the search process and made sure that only those studies that were applicable directly to the review question were included in the search.

Study selection:

The process of selecting the studies explains how the literature that is directly related to the review question was identified, and the PRISMA diagram by Page et al. (2021) provides a clear idea of this process (see figure 1). The extraction of duplicates left 545 results, 299 of which were irrelevant articles filtered out by reviewing titles and abstracts, this process allows concentrating on the studies related to the review question. Another screening process against inclusion criteria reduced the number of articles to 36 further exclusions.

Critical Appraisal

The procedure of critical appraisal for any research study have their respective strength and weaknesses in terms of its evaluation power and the quality and relevance of the article selection in respect to the research question. The CASP checklist is designed for qualitative research studies and in the current appraisal process, (Long, French, & Brooks, 2020). Recommend its importance in the specificity of the tools that have checklists which show the qualitative research to show ‘rigour’, where the ‘decisional quality’ of including the study for analysis. It needs to eliminate research self-selection bias, and adopt a thorough assessment guided by professional standards.

Critical Appraisal: Barakat & Franklin (2020): Nursing Workflow and BCMA

The research overview and background by Barakat & Franklin (2020) explores barcode medication administration (BCMA) advocated for reducing medication errors. This area of study and its effect on the nursing process is not well studied. This research aimed to evaluate the impact of BCMA, when included to the existing electronic prescribing and medication administration (ePMA) system over the nursing practices in UK teaching hospital. The researchers used research approach that comprised of comparative study, on two similar surgical wards. This process consisted of using direct observation at 8 AM each day for 10 consecutive weekdays in each ward especially during the drug rounds. Data gathered were on drug round time, where the aspect of punctuality, identification of patient, and the last one was on medication cross verification. The study identified and determined that there was no significant difference in the overall time per round of drugs, and that this time was about 68 minutes per round on both wards. The mean time per dose however was significantly lower on the BCMA ward (2.3 minutes) than the non-BCMA ward (4.2 minutes). Importantly, patient identification checks went from 74% to 100% with the use of BCMA.

The strengths of the research method included the direct observation by a single observer which can help in the consistency of finding and can minimize the limitations of self-reports. The study, which involved observation of nurses in an actual context, allowed to record nuanced patterns of their workflow-workaround, for instance walking paths, with spaghetti diagrams while an integrative view as per (Fraczkowski, Matson, & Lopez, 2020) findings was not done. This approach provided a visual comparison of the activities streamlined through the use of BCMA, and demonstrated there was consistently less walking to the medicines room overall on the BCMA ward. Moreover, if BCMA is compared to an existing ePMA system rather than a paper-based system, the assessment would be more relevant for modern NHS trusts where there is already a digital system in place while its application in different medical fields (Vanderveen, & Husch, 2015) could have given more insights.

When critiquing research methods, it was found that a major drawback in conducting the study was the fact that the study was carried out in two wards as opposed to a single ward before and after implementation but it missed, where (Vanderboom et al. 2016) showed interdisciplinary team feedback to BCMA success was acheived. Nursing leadership, culture, and patient acuity were also different by wards, and may cause bias in this physically similar surgical units while (Giraldo et al. 2018) captured their perception about mobile apps based interventions in workprocesses. The data collection on the BCMA ward was only four days after implementation, and staff may not have had the opportunity to become acquainted with the system which could have influenced the results. Moreover, there was no quantitative assessment of the various categories of nursing activities, which restricts the thoroughness of the research workflow data capture and data analysis while the research missed on quality tools (FMEA failure mode effective analysis) as described by (Thompson et al. 2018) in reduction of errors, or the BCMA transition experience of nurses using eprescription in electronic health record system as per (Reale et al. 2023).

Twenty drug rounds were sampled, 10 at each of the two wards. This study looked at the administration of 47 patients on the non-BCMA ward and 43 patients on the BCMA ward, whereas other longitudinal studies analyzed 613,868 administrations. The number of different nurses observed in each ward was low (7 or 8), and may not have been representative of the broader nursing profession. There is a relatively small number of subjects and the study involves only one institution so it is hard to extrapolate the results to other institutions that may have different methods of medication giving, while it missed out on nurses treating inpatient-outpatient using BCMA effectiveness as highlighted (Post et al. 2023) study.

Results indicate that BCMA standardizes and harmonizes the way medicine is administered without putting additional time pressure on the nurses. A big safety success is the 100% patient identification rate, though the researchers noticed some workarounds, such as nurses scanning a patient’s barcode sticker on their notes rather than on patient wrist bands in side rooms, while (van der Veen et al. 2020) showed factors important for workaround methods for nursing while the behavioural dimensions of nurses (Grailey et al. 2023). This means that although the system is in place to check for identity, there can be counterproductive practices due to environmental barriers such as tethered scanners. The less time per dose, may be an opportunity for more timeliness if drug rounds are started on time.

Critical Appraisal- Fisher et al. (2023): Medication Safety during COVID-19

Following the COVID-19 pandemic which caused massive disruption to UK Primary Care, a study by Fisher et al. (2023) study on ‘Medication Safety During COVID-19′ raised concerns about hazardous medication prescribing. The aims of this study was to check the use of ‘OpenSAFELY’ platform to describe how the pandemic is affecting medication safety indicators. The researchers based their study on 57 million patients, in NHS and applied a population-based, retrospective cohort design. They adopted 13 ‘PINCER’ (Pharmacist-led Information Technology Intervention for Medication Errors) indicators, which determine the risks for gastrointestinal bleeding among others and required monitoring via blood tests. Concerning this study, it was determined that hazardous prescribing had not undergone major alterations throughout the pandemic. Monitoring in October 2021 slightly deteriorated for blood ACE inhibitors (from 5.16% to 12.14%), with recovery of most indicators by September 2021 while it has missed the controlled trail for cost effectiveness (Avery et al. 2012).

In this study, the researchers used federated analytics – a way of high-security analysing pseudonymised primary care records from 95% of the English population, without data being moved. This means it is 100% transparent, reproducible: all of the code used for analysis is publicly available on GitHub. The study covered the entire national scale, which was not possible in past manual audits, because of running the same code in both environments. This approach values patient confidentiality both as patients and as public health reports and encourages near real-time status updates on key public health challenges. However, it does not capture (Avery et al. 2012) cost effectiveness of workmethods in institutional.

Critique of research methods did however, reveal that the findings are largely descriptive and that the researchers did not attempt to statistically examine the significance of the changes that were made apparent. Long-term seasonal trends in the rates of indicators could not be taken into account because of the study period, especially the time prior to the pandemic. In addition, only prescriptions and tests done in primary care were captured; those communicated via hospital letter and telephone were not captured as structured data. This could lead to an overestimation of the lack of monitoring in some patient groups.

No study has captured such a large sample size – of around 56.8 million patients across 6,367 GP practices. This huge data set allowed the identification of 1,813,058 patients who were at risk of experiencing at least one potentially hazardous prescribing event during the 2 years of this study. This extent of a population – at National level – removes sampling error to a level of virtual extinction and gives a complete picture of medication safety within different populations and areas of England.

The study suggests that, concerning medication safety, the NHS primary care system was very resilient during the pandemic. Some hazardous indicators, such as NSAID prescribing among the elderly may not reflect deliberate safety measures, but may instead reflect fewer acute presentations. The lengthy timeframe associated with ACE inhibitor monitoring, however, does reflect the focus primary care clinicians had toward practicing higher risk monitoring (e.g, methotrexate) when resources were limited. They illustrate that federated analytics can help guide policy decisions regarding which services we should try to provide focused recovery assistance following systemic shocks.

Critical Appraisal- Rodgers et al. (2022): Scaling-up the PINCER Intervention

Research overview scaling-up the PINCER intervention by Rodgers et al. (2022) showed that medication errors in general practice contribute significantly to hospital admissions and avoidable deaths. This study sought to investigate whether the PINCER intervention—a pharmacist-led IT system that identifies at-risk patients—remained effective when rolled out at scale. Using a multiple interrupted time series design, the researchers tracked the intervention across 343 general practices in the East Midlands. The study measured 11 prescribing safety indicators over 16 quarterly periods. Findings showed a 16.7% reduction in hazardous prescribing at 6 months and a 15.3% reduction at 12 months post-intervention. The most significant improvements were seen in indicators for gastrointestinal (GI) bleeding risk, which fell by 23.9%.

The interrupted time series (ITS) design is a robust method for evaluating large-scale interventions where randomisation is not possible due to logistical or commissioning constraints which (Danda, 2026) research using informatics. By including calendar time as a covariate, the researchers accounted for secular trends toward safer prescribing that might have occurred regardless of the intervention which is an advantages of research methods. The use of logistic mixed models allowed for within-practice correlations and provided adjusted odds ratios that enhance the reliability of the findings. Furthermore, involving PPI representatives in the design ensured that the research remained focused on patient safety and welfare while factors was identified by (Laing et al. 2022).

As an observational study, the findings may have been influenced by unknown confounding factors or behavioural changes unrelated to PINCER. The researchers were unable to collect follow-up data for all practices; by 12 months, the number of contributing practices dropped from 343 to only 70. This significant attrition could introduce selection bias if only the most engaged practices continued to upload data. Additionally, the term “without co-prescription” was kept in the denominator, which might have underrepresented the true effectiveness of adding protective medications like proton pump inhibitors while (Elliott et al. 2013) research highlighted pharmacist based economic impact in medicine management.

The study initially searched 2.97 million patient records at baseline, making it one of the largest evaluations of a medication safety intervention in primary care. While the 12-month follow-up was limited to 70 practices, the sensitivity analysis showed that the characteristics of these practices remained comparable to the original 343. The large initial sample size provided enough power to detect small but clinically significant changes in hazardous prescribing across multiple drug groups, while (Daniel, 2013) findings found how this was assessed in emergency departments managed by nurses.

The results strongly support the national rollout of PINCER in England. The sustained reduction in GI bleeding risk indicators suggests that the intervention is most effective when it prompts a straightforward clinical action, such as prescribing an ulcer-healing drug. However, the study found no reduction in hazards related to asthma or stroke, speculating that these changes are more difficult for pharmacists to implement due to complex patient indications. This highlights that IT interventions need to be coupled with clinical support to address more nuanced prescribing challenges.

Critical Appraisal- Sheikh et al. (2022): ePrescribing Systems in Hospitals

Sheikh et al. (2022) study on ePrescribing Systems in Hospitals stated background errors in hospitals in everyday operations are common. This eventually leads to avoidable morbidity and mortality. This multimethods research programme was sought to describe the implementation of ePrescribing systems for estimating their effectiveness and cost-effectiveness in the operations while (Cresswell et al. 2013) study found that early interventions help to reduce errors. Six longitudinal case studies across diverse hospital sites was carried out, combining 242 interviews with 32.5 hours of ePrescribing systems observation in this research. The researchers also developed ‘IMPACT tool’ via an eDelphi exercise, in order to track the list of 80 high-risk prescribing errors. The study found that while implementation of ‘ePrescribing systems’, was difficult due to integration issues, ePrescribing was associated with a significant reduction in error rates. The earlier scores from 5.0% was reduced to 4.0%, at two of the three sites, where effectiveness was measured.

The theoretically the authors tried to ascertain the naturalistic evaluation method that offered a rich, context-heavy understanding as to why any systems are failing or succeeding while (Williams et al. 2020) where optimising hospital eprescription was found with planned interventions succeeding in NHS hospitals shown by (Crowe et al. 2010) research. By using a Bayesian framework in the research approach that was used for health economic analysis the researchers synthesized the aggregate expert opinions (priors) with empirical study data. This helped to generate meaningful posterior distributions. It is advantageous for “upstream” outcomes as the research on the clinical errors, where a minute incident or chances of error, leads to higher case of mortality was tackled. It was found that the online ePrescribing Toolkit was a tangible evidence for connecting all stakeholders in NHS.

Implementation delays forced the researchers to abandon their planned stepped-wedge design in favour of a less rigorous pre- and post-implementation design. This limited their ability to make a clear causal inferences existing ‘online ePrescribing Toolkit’ systems’ impacts. The researchers faced data access and data capture in regards to the economic factor ‘cost data’ from the hospitals. This forced them “headroom” approach that helped them to maximise the justifiable prices over the direct cost-effectiveness. Small number of case study made it difficult for the researchers, in order to generalize the findings throughout the NHS.

Researchers were able to use qualitative sample that included 242 interviews. This research approach to sampling offered to capture a broad range of stakeholder perspectives from clinical implementation teams to end user patients. The use of the drug charts from 2,422 patients were reviewed for the safety analysis which had 28,526 medication orders. The current research did show large dataset, enough to identify significant reductions in common procedural errors. The study detected a 1.5% reduction in errors in ‘online ePrescribing Toolkit’ systems’. However, there were limited number of hospitals (only three went live during the study) implies the between-site variance could not be reliably estimated while (Heeney et al. 2023) used qualitative approach for ‘why’ and ‘how’ about interoperatability of eprescribing systems while (Bell et al. 2019) used mixed method to understand CDS in eprescription in UK. .

Findings showed that ePrescribing is a complex organisational intervention. It is simply not just a technical one. The outcomes of the research benefits showed -improved legibility and completeness are common but (Cresswell et al. 2017) study offered workaround for nurses in eprescription systems adoption. However, the study warned that ‘online ePrescribing Toolkit’ systems’ introduces a new risks if not properly configured. Authors found that only few hospitals, which used restrictive clinical decision support (CDS) saw specific errors eliminated. But again (Pontefract et al. 2018) showed that there is a general reluctance by the institutions for commercial viability skepticism, to fully deploy CDS. The pre-post study, due to fears high degree of stakeholder involvement to ascertain the errors, and associated effort fatigue. Alagiakrishnan et al. (2005) showed how it is important to reduce and remove inappropriate medication in the healthcare system where CDS plays a key role. It is a system beyond human optimization, using data driven analysis and output helping internal stakeholders to adopt, culture of continuous learning that are essential to realizing long-term patient safety benefits.

Critical Appraisal- Williams et al. (2025): Longitudinal BCMA Adoption and Safety

Williams et al. (2025): Longitudinal BCMA Adoption and Safety BCMA systems are touted as a method to provide the “five rights” of medication administration, and they must be adopted by users to be effective, as noted in Longitudinal BCMA Adoption and Safety by Williams et al. (2025). This was a retrospective longitudinal study looking at the BCMA use and the barriers and enablers in a London NHS Trust over a 16 month period. Five wards provided 613,868 administrations and this data was analysed along with prospective clinical observations. The study showed a high range of rates of wards scanning medicine from 5.6% to 67%. There was a fall in compliance over the years in most areas, with one ward (N1) that had a quality improvement (QI) initiative showing an increase. There were “safety catches” with 37% of mismatch alerts leading to an adjustment of user action in total.

One of the benefits is that it is a longitudinal study, and compliance is tracked over the course of 16 months, shedding light on compliance after adoption has taken place for more than 16 months. When the researchers blended big data from EHRs with observations made from a contextual inquiry, they were able to gain insight into the “why” behind the numbers. For example, observations were made to explain that common reason codes such as “barcode unreadable” were in many instances simply a method of popping the system when under pressure for time. However, study of (Svandova, & Smutny, 2026) stated that minimising workaround needs to ascertain deviation of work paths or methods, uncovering specific factors, such as medication formulation, nurse behaviour, technical fault, that have a significant impact on the rate of scanning.

The study took place in one trust with significant digital maturity, therefore results may not apply to other less maturing trusts. Data was collected in the time of COVID19 pandemic which did undoubtedly affect clinical workflow and limited the frequency of observations for the researchers. Also, the safety catch data analysis period was only one month, and the extent to which this is representative of long-term safety effects is unknown. The study also indicated that non-error events (e.g., two half dose tablets) cause trigger alerts. However, it did not capture a home based drug administration by (Shore et al. 2024), which could be overestimating the safety benefits of holistic healthcare delivery system.

The number of administrators in the data-based sample was huge (613,868), giving the regressions a lot of power to determine the relationship outcomes in variables. But the clinical observations were performed only once in each area, and included only eight areas. The majority of the wards where retrospective data were relied on were different than the wards, where the observations were carried out, and thus some of the qualitative data may not fully account for the quantitative data across the five over-arching wards studied.

The influence of contextual factors, like specialist ward type or workload of nurses, on the success of BCMA, is shown. Grailey et al. (2023) capture the barriers and faciliators in their study, especially in the fast-paced work environments which required to understand behavioural capability along with CDA and eprescription. Previously  unsustainable for scanning on the acute medical unit, as evidenced by the speedy drop in AMU scanning. In contrast, the high scanning levels in Ward N1 shows that nurse-led QI projects and ongoing commitment can help to maintain high levels of scanning. The results highlighted that BCMA systems are not “set and forget” technologies, while it supported earlier study of (Popat et al. 2024) set in NHS, and that they need continuous monitoring in order to keep them effective as safety barriers.

Chapter 4.0: Synthesis

Theme 1: Social and technical barriers in workflow process

The first theme that emerges strongly across the research journal shows the emphasis of the use of electronic interventions in the healthcare management process and especially when the adoption of digital systems requiring to align with the clinical practice the workflow work around needs to be categorically instituted (Williams et al. 2025). The author argued that ward management by hour, is necessary to check dosage omissions, which represents micro-macro dimensions of workflowprocess to be improved as workaround, in real time. This theme also calls for BCMA context the aspect of changing workarounds in existing workflow process needs for example linking barcode sticker of patient with patient notes bypassing primary safety check of patient identity as per (Barakat & Franklin, 2020). A change in the eprescription settings shows lack of integration between the workflow methods, the modules, the prescribing methods as highlighted by (Lundhaug et al. 2025), that is forcing the clinicians to do repetitive tasks (multiple times) alternating between using paper based intermediaries and digital which is creating new risks in patient safety which was also found in Saudi Arabia hospitals (Alharthi, 2024). Rodrigues et al. (2024) argued this to be a multidimensional construct for the workarounds in relation to the hardware limitation (in the rooms or ward), the software immaturity. The human factor of time based workload pressure in a formalized job setting, which is doing potential harm by increasing the risk factor (Sheikh et al. 2022). From the patient perspective introduction of technology in the healthcare management process and the patient involvement has caused removal of paper based medication information to digitalization of new form of eprescriptions, which is a continuous learning process for the ‘patient-clinician-doctor’ (Sheikh et al. 2022). While implementation success is dependent on ‘culture of use’ by frontline staff, system configuration, bringing iterative optimisation overcoming technical limitations in formal practice as discussed by (Williams et al. 2025).

Theme 2: Longitudinal compliance in BCMA

The second theme that emerges strongly is about the barcode medication administration system rule that request to verify the five rights the scanning the patient wristband the medication documentation barcode making it user compliant in the clinical context as highlighted by (Williams et al. 2025). The longitudinal nature of the research showed how systematically scan mismatch alerts have captured wrong patient order, discontinued/expired order drug and wrong patient wristband, scanned to be eliminated. The longitudinal study showed how medication scanning has reduced the workflow process time lines improve the accuracy rate and eliminated the risks as the frontline workers were becoming stressed (Williams et al. 2025) that was evident with (Sheikh et al. 2022) developing ‘critical error types’ IMPACT tool systematically reducing errors over time (reducing 21138 opportunities of error), improving cost effectiveness across eprescription lifecycle implementation to system optimisation. Evidence from the study showed a high of 67% medication scanning rate in acute medical units in a high work pressure environment to yield error as low as 5.6% is testimony of longitudinal iteration based improvement. The longitudinal implication of using BCMA guidelines have shown a change within the stakeholders especially users in action and capturing the ‘safety catch’ in errors especially the wrong patient respond or expiry orders of medicine (Williams et al. 2025). Additionally decline in compliance was also noted in a logistical barrier perspective when there was malfunctioning of the medical hardware software and barcodes that are unreadable or unavailability of the scanners which proves how environment and system improvement is a longitudinal effort in medical quality management. Evidence from these studies show micro level locally laid quality improvement practices in real time that captured the frontline employee feedback and with able nursing leadership across the words helped the system to sustain and improve the scanning rates in eprescriptions thereby proving BCMA technology and compliance to be beneficial.

Theme 3: Institutional eprescribing decision and CDS

The third theme that emerges strongly is a evaluation of the NHS hospitals that have primarily accepted hospital eprescription as a system and incorporating the clinical decision support system along with computerized provider order entry CPOE (Sheikh et al. 2022). Eprescribing impact on the work methods eliminated the human errors, in existing paper system and associated issues of incomplete orders, illegible handwriting and inappropriate drug administration dosage to patients, but  (Schmidt et al. 2026) stated the continous challenges of serious configuration with systems, alerting humans is technology induced error reduction system across the health institution still remained which was found in Swedish health care study by (Rahman Jabin, & Hammar, 2022). It is evident technology use in prescribing underwent a transition, that has been prolonged and challenging from institutional perspective, with implementation delay in error defects identification, defect reduction in specific task area, that has helped the hospitals to standardize the process. While the aspect of nursing perception (Jaber et al. 2025), significant reduction across wards/departments in the hospital but equally important IT system, system design and information system design, which has helped CDS to aid the human fatigue. The applicability of the system output, eliminating the probability of potential error types, in the patient management system was found by military hospital (Alanazi et al. 2024) expanding scope of the findings. The institution faced challenges in implementation, optimizing and standardizing, the ‘commercial off the shelf’ (COTS) products into an adaptable home grown system. Findings match with (Khan et al. 2022) who argued that it required the contribution of the internal stakeholders, apply wireless technology for easy integration within medical devices. It needed to focus on the alignment of the system and the clinical workflow against the existing job descriptions, to match and be effective. As institution, the hospitals had resource and technology challenges, and which (Wu et al. 2022) argued in terms of maximizing human efficiency, automate workflow process efficiency. This is achieved through design, architecture, and data analysis in order to realize the full potential in reducing the patient term by adopting a long-term system optimization approach.

Theme 4: Pharmacist led IT interventions

Across the research studies the last thing that emerges strongly is in relation to the pharmacy within the healthcare institution and how large scale evaluation system PINCER (Pharmacist lady information technology intervention for medication errors was developed and applied as an effective tool to reduce the hazardous prescribing workflow methods in primary healthcare setting (Fisher et al. 2023).   This team have shown that usage of pharmacy technology caregivers and the patients have an equal role to play in order to identify the probability of risk, risk types, and eliminate the chances of ‘risk of harm ‘through an educational outreach embraced by the stakeholders.  The studies prove that pincer associated with the healthcare institutions decreased hazardous prescribing workflow methods within six months from 15.3% decrease over one year, post-intervention and from disease perspective (gastro-intestinal GI bleeding) using drugs decreased to 24% levels in patients due to NSAID hazardous drug prescription tracing system (Rodgers et al. 2022). Open supply platform have shown the resilience of the platforms, against the external shocks, like COVID19 pandemic that disrupted the primary care services, from institutional perspective, thereby, focusing how pharmacy and its role in high risk medications. It matched with a Czech study (Berger et al. 2023) set in COVID19 on eprescription system, as the required technology centric interventions to scope out the risks and achieve performance in the institution (Fisher et al. 2023). The application of pharmacy related IT tools therefore, captured the pharmacy supply chain ‘end to end’ creating a robust framework, of continuous safety monitoring practices on pharmacy workflow, nursing workflow (Yu et al. 2025) echoed the findings which is changing the human habits and translating to shift towards an automated risk detection system, helping in sustain clinical improvement environment (Rodgers et al. 2022).

4.1 Discussion

The above result synthesis help us to understand that electronic prescribing system, and the dimension of barcode medication administration, at the institutional level especially, for the health care sector that has significantly enhanced the institutional capability and frontline employee delivery efficiency directly impacting the patient safety. The mix of technology, information capture, information processing, systematically have helped the institutions, to reduce the rate of medication errors, which are clinically vital for the organization to prove its operational efficiency. The synthesis of the multi-method research in the above topic, have specifically shown how NHS hospitals demonstrated a transition from a paper based prescription system to an electronic or eprescription system over the months and years by systematically overcoming the challenges in implementation.  The internal stakeholders have you illustrated you have understood the paper and digital platform the dimension of errors and the implications of the typology of risk that impact the clinical delivery efficiency and the institutional commitment to patient safety system. Even though the technology reduces the adversity of the prescription drugs, the pharmacy involvement in capturing data of the supply chain, and the work method and workaround processes have reduced the chances or adversity of mismatch prescription drugs probability and its outcome on the patient health safety. Similarly, the technology accessed by the institutions which had procedural errors previously like incomplete drug orders inappropriate dosages and illegible handwriting have been eliminated completely with the aid of clinical decision support system (CDS).  It can be concluded that the role of technology across the length and breadth of clinical management in the healthcare industry, cannot be ignored though the internal stakeholders have to reconfigure information technology (IT), information systems (TI), databases, to understand the source of errors, error types, cost-time impact on the degree of hazardous liability on the institution and on the patients. The above evidence of focused on -anticoagulants, antiplatelets and NSAIDs, where epharmacy role, now enabled tools and platforms, with electronic interventions, that have helped preventable medication related hospital treatment and admissions.

From the nurse nursing perspective application of BCMA has provided a important and critical safety layer, where the point of care complied with the ‘five rights’ verification which is indirectly resulted in active patient identification 100%. Legacy work method and work process in paper based prescription have shown mismatch of data that was overcome by bcma system which changed with the digital shift in the frontline user action and the higher level information technology algorithm that acted as safety catch in identifying and determining the error from the perspective of expired medication in the system or tracking a wrong patient order. It is evident that the studies reflect long term trend by the internal stakeholders in improving the existing workflow method system and trying to comply with high pressure work environment with zero error delivery in departments/ wards, where longitudinal quality improvement practices have helped to standardize the system capability and frontline delivery. The role of nurses embracing E prescription technology therefore has improved the legacy work methods to a new workflow to work around system reducing the time eliminating the errors and also achieving cost efficiency in serving per patient from institutional context.

The ever results also help to emphasise on the technology which has played a huge roll in reducing the drug adversity and its impact on the patients from healthcare service delivery perspective. All the interventions of the tools platforms any prescription system was off the shelf but have been implemented and adopted by the healthcare institutions with significant iterative system optimization happening in each department and ward. This adoption and adoption is a supportive organizational culture by the internal stakeholders as regular feedback from the patients from the nurses with that have helped the healthcare organization to clinically adhere with the high compliance KPIs and prevent the existing system of patient safety benefits erosion. The role of nurses with pincer automated computer platform technology that searches hazardous prescription in post intervention have shown the power of technical framework to catch errors aiding the human decision making process in ensuring the nursing role in patient safety and also integrating the technology with the clinical new workflow methods. Their role has also been critical in utilizing technology and human judgment to mitigate the diverse risks in their task areas and the safety threats in the old workflow method and also in the transitional period of workflow method changing from traditional paper base prescription to eprescription process.

4.2: Limitations

Firstly, the studies of (Roger et al. 2022) and (Fisher et al. 2023) acknowledge that observational research method to ascertain the confounding factors and determine the causal inferences is a methodological limitation while (Sheikh et al. 2022) and (Rogers et al. 2020) had to abandon the stepped wedge design in research due to delays and it’s robust people’s research comparison. From geographical perspective the studies in the region of East Midlands or in London may not represent the entirety of picture of NHS healthcare organization as the inability to understand the transparency of cost data remained a hurdle for bringing about the change in relation to the research topic (Sheikh et al. 2022). Many studies like (Barakat & Franklin 2020) and (Williams et al. 2025) have captured short observation windows as defaced the attrition in follow-up data in the health care institution, while Rogers et al.(2022) had to complete all the research method within a year, with 70 practices captured as a baseline. More recent studies in 2026, in relation to eprescriptions and sociotechnical workaround, required to be captured, for understanding the involvement of artificial intelligence (Ai), and human decision fatigue, that the above studies have not fully captured and discussed.

Chapter 5.0: Conclusion

The current study aim to understand ‘how patient safety is impacted by technology usage and how it reduces the adversity of prescription drugs, using electronic prescribing system at institutional level’. The results in the last chapter have shown that there is a significant impact of multiple information technology systems generated for internal stakeholders in healthcare organization, which has significantly improved the work methods, work processes and enabled him to improvise on new work approaches. It can be concluded that electronic interventions in eprescribing systems like BCMA and pharmacist led IT platform based tools like PINCER have helped healthcare organizations significantly to improve and enhance the patient safety levels by systematically adopting quality interventions an iterative reduction of medication risk. The outcome showed BCMA compliance helping nurses, in achieving over 100% patient identification eliminating mismatch cases and preventing errors at 37% of instances and 16.7% reduction in PINCER based hazardous prescribing even during COVID-19. There is high degree of socio- technical alignment, which was required to maximize the effectiveness of the organizational throughput in meeting the compliance, which was found to decline overtime in a high pressure word in the healthcare institution. The involvement of CDs clinical decision support system helping the humans in the healthcare system have helped technical power to identify error track the error offer real time restricted alerts aiding the success of the workflow around through iterative optimization process. It can be concluded that the transitional journey from paper to digital shift in prescription requires the what methods the culture to show digital maturity, in achieving a set goal or clinical outcome while installing technical software and aligning the ‘culture of safety’ in everyday work process.

5.1: Implications for Practice

The above research showed the transitional journey to be a challenging for the healthcare institution from top-level view, against the frontline nurses and their work around methods at micro level to be a key element, from a reactive-error correction and pro-active risk removal perspective. It showed that the system design in the clinical workflow, requires integration, alignment and collaboration, from multiple departments/wards, IT-IS from task perspective. This helps the practice followed to embrace, eliminating the legacy system and implementing IT based workaround which requires normalizing, standardizing to achieve 100% patient safety identification, amidst high pressure work conditions.

   5.2: Recommendations:

1. Suggestions include to expand PINCER integration to 100% automated pharmacist led supply chain information system, at national level and focus on implementing high risk drug group patients to be threat free.
2. Institutional prioritising of restrictive CDS and sharing the data with multiple organizations would help to eliminate the procedural and system based clinical errors entirely in case of extreme risk based prescriptions.
3. The alignment of hardware software accessibility at institutional level is required to enable collaboration between the healthcare organisations a nursing data for a top level perspective of eprescription effectiveness across nations.
4. Ergonomic medical scanning devices that are wireless for the nurses is required to remove the physical barriers preventing bedside workarounds in side rooms.

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