# Improving Patient Safety and Clinician Cognitive Support Through eMAR Redesign

> **NIH AHRQ R01** · MEDSTAR HEALTH RESEARCH INSTITUTE · 2020 · $398,492

## Abstract

Project Summary/Abstract Written
The objective of the proposed research is to reduce the patient safety hazards associated with
electronic medication administration records (eMARs) by, (1) understanding current usability
and safety gaps, and (2) creating design and development documents, wireframes, and
prototypes to serve as the foundation for future eMARs that will eliminate these gaps. In
particular, we focus on communication and information flow challenges between nurses,
pharmacists, and physicians during medication administration and use of the eMAR. The
proposed research is in direct response to special emphasis notice (NOT-HS-16-009). We
will develop a broad understanding of usability and safety hazards associated with eMARs by
analyzing a large dataset of 1.7 million patient safety event reports and detailed medication
error related narratives. We will then conduct heuristic analyses of current eMARs, and
interviews and observations of physicians, nurses, and pharmacists. These data will serve to
inform the development of eMAR design documents, wireframes, and prototypes as the
foundation for future development.
This project utilizes the extensive expertise of the research team in human factors and safety
science, health information technology (health IT), informatics, and data science. Our research
team includes physicians, nurses, pharmacists, and human factors engineers, and experts in
natural language processing. In addition, our partnerships include a patient safety organization
and a health IT vendor. The proposal addresses fundamental aspects of the call for proposals
by providing new insights on the safety of health IT and improves current practices by
developing use cases and new prototypes for immediate use by healthIT vendors.
Contributions from this research will include a fundamental understanding of the role of health IT
during medication administration with a focus on communication and information flow, design,
development and testing documents for vendors and providers, and eMAR wireframes and
prototypes to improve development. Our research will also provide organizations like the Office
of the National Coordinator with medication related test scenarios to assess current health IT
systems.

## Key facts

- **NIH application ID:** 9912124
- **Project number:** 5R01HS025136-03
- **Recipient organization:** MEDSTAR HEALTH RESEARCH INSTITUTE
- **Principal Investigator:** Raj M Ratwani
- **Activity code:** R01 (R01, R21, SBIR, etc.)
- **Funding institute:** AHRQ
- **Fiscal year:** 2020
- **Award amount:** $398,492
- **Award type:** 5
- **Project period:** 2018-07-01 → 2023-04-30

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/9912124

## Citation

> US National Institutes of Health, RePORTER application 9912124, Improving Patient Safety and Clinician Cognitive Support Through eMAR Redesign (5R01HS025136-03). Retrieved via AI Analytics 2026-05-22 from https://api.ai-analytics.org/grant/nih/9912124. Licensed CC0.

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