Building Medication Safety into Health IT

Medication safety is central to both clinical care and the systems that support it. Every medication order, administration, and confirmation is an opportunity to prevent harm. For health IT professionals, understanding how safety principles translate into system design is what makes the difference between a workflow that protects patients and one that introduces risk. 

The foundation of medication safety is based on the “5 Rights” of medication administration. These principles have long guided clinical practice, and they continue to shape how electronic systems are built and maintained:

✅ Right patient
Every order and administration must be tied to the correct individual

✅  Right medication
The drug, formulation, and concentration must be accurate

✅ Right dose
The prescribed amount must reflect the patient’s needs

✅ Right route
The method of administration must match the order (oral, IV, topical, etc.)

✅ Right time
Medication must be given at the intended time and interval

For clinicians, these steps are ingrained in daily practice. For health IT professionals, they are design requirements that determine whether safe practice is easy to follow or easy to bypass.

👤 Right patient

One of the most serious risks in medication management is giving a drug to the wrong patient. In the EHR, safeguards should make it clear and simple to confirm identity. Patient banners must remain visible and consistent across screens. Photos embedded in the workflow provide another layer of assurance, while alerts for similar names reduce the chance of mis-selection. At the bedside, barcode scanning ties the wristband directly to the active order, closing the loop before administration.

From a design standpoint, these features need to feel natural. If identity checks are hidden, inconsistent, or time-consuming, users are more likely to rush through or skip critical steps. The strongest designs keep verification tasks visible, quick, and reliable so that the safest path is also the easiest one to follow.

💊 Right medication and right dose

Medication and dose verification are where decision support plays its most visible role. In the EHR, this includes things like allergy checking, drug–drug interaction alerts, duplicate therapy warnings, and weight-based dosing calculators.

The challenge lies in configuration. Thresholds that are set too broadly create constant interruptions, leading to alert fatigue. If set too narrowly, real risks are missed. Health IT teams need to work with clinicians to design and configure these rules carefully, aligning them with the care setting and adjusting as knowledge evolves.

When decision support is configured well, it strengthens clinical confidence and reinforces safe practice. Poorly tuned systems erode trust, and clinicians begin overriding alerts without consideration. Ongoing maintenance, specialty-specific adjustments, and feedback from users are essential to keep these safeguards effective.

⏱️ Right route and right time

Route and timing are both safety concerns and workflow considerations. EHR systems should display the intended route clearly and require confirmation before administration. Scheduling tools need to calculate due times automatically, send notifications when medications are approaching, and provide smooth workflows to document late or missed doses. For PRN (as-needed) medications, guidance on parameters must be built into the workflow.

Integration with the medication administration record (MAR) is essential. Mobile tools at the bedside make it easier for clinicians to verify both route and time without leaving the patient. Systems that create artificial timing constraints or require unnecessary navigation invite unsafe workarounds.

Good design respects the realities of care delivery while still reinforcing safe practice. Technology should guide clinicians without boxing them into workflows that don’t fit the situation at hand.

⛑️ Technology as a safety partner

The 5 Rights remain clinical responsibilities, but technology strongly influences how reliably they are carried out. EHRs and related systems should provide context, reminders, and verification steps that reinforce clinical decision making without reducing it to a series of clicks. 

Getting this balance right requires thoughtful configuration, regular monitoring, and collaboration with clinical teams. When health IT and clinical practice are aligned, the result is safer medication administration and stronger trust in the systems that support it.