The aim of the present study was to identify and quantify medication errors reportedly related to electronic medication management systems (eMMS) and those considered likely to occur more frequently with eMMS. This included developing a new classification system relevant to eMMS errors. Eight Victorian hospitals with eMMS participated in a retrospective audit of reported medication incidents from their incident reporting databases between May and July 2014. Site-appointed project officers submitted deidentified incidents they deemed new or likely to occur more frequently due to eMMS, together with the Incident Severity Rating (ISR). The authors reviewed and classified incidents. There were 5826 medication-related incidents reported. In total, 93 (47 prescribing errors, 46 administration errors) were identified as new or potentially related to eMMS. Only one ISR2 (moderate) and no ISR1 (severe or death) errors were reported, so harm to patients in this 3-month period was minimal. The most commonly reported error types were 'human factors' and 'unfamiliarity or training' (70%) and 'cross-encounter or hybrid system errors' (22%). Although the results suggest that the errors reported were of low severity, organisations must remain vigilant to the risk of new errors and avoid the assumption that eMMS is the panacea to all medication error issues. eMMS have been shown to reduce some types of medication errors, but it has been reported that some new medication errors have been identified and some are likely to occur more frequently with eMMS. There are few published Australian studies that have reported on medication error types that are likely to occur more frequently with eMMS in more than one organisation and that include administration and prescribing errors. This paper includes a new simple classification system for eMMS that is useful and outlines the most commonly reported incident types and can inform organisations and vendors on possible eMMS improvements. The paper suggests a new classification system for eMMS medication errors. The results of the present study will highlight to organisations the need for ongoing review of system design, refinement of workflow issues, staff education and training and reporting and monitoring of errors.

Background Victorian hospitals are at various stages of transition to electronic medication management system (EMMS). Although improvements in medication safety and error reduction are assumed when using an EMMS, concerns have been raised regarding potential unintended consequences and possible new error types, so information from frontline staff using EMMSs provides an insight into their safety and some of the risks associated with their use. Aim The aims of this study were to determine the perceptions of frontline staff using an EMMS regarding the safety of the EMMS and the potential for new errors or those errors that were more likely with the use of an EMMS, and providing this feedback to the participating organisations. Method Frontline clinical staff in eight Victorian hospitals using EMMS were invited to participate in voluntary, anonymous online survey designed and analysed by experienced medication safety pharmacists. Results Respondents (n = 664) included medical officers (30%) nurses (49%) and pharmacists (16%). Forty‐eight percent of respondents have observed, investigated or reviewed errors/near misses in EMMS. Fifty‐six percent believe that these errors/near misses are a new type of error related to EMMS. Top issues identified by those involved in an error (195) were incorrect patient selection and incorrect dose scheduling, resulting in dose duplication. Fifty‐six percent agree or strongly agree that EMMS has reduced the potential for medication errors and 58% consider that EMMS has introduced new types of errors. The most significant issues raised about EMMS were time‐consuming and non‐intuitive processes and overdependence on technology. Conclusion Staff experience and perception of EMMS was overall positive, most considering that medication error risk is reduced, but safety concerns remain to be addressed.