OBJECTIVE: This study aimed to explore the challenges pharmacy students face when learning to detect medication-related problems (MRPs) in electronic health records (EHRs) during simulated patient work-ups and offer implications for instructional design in pharmacy education. METHODS: A qualitative research design was employed to analyze responses from 120 third-year pharmacy students enrolled in a required course. The students completed open-ended surveys at the end of the semester, describing the difficulties they encountered while working on patient cases in a simulated EHR. Inductive thematic analysis was used to identify recurring themes related to the students' challenges. RESULTS: The analysis revealed 3 macro-categories of challenges: (1) Work-up Process, including rushing through tasks and overlooking information
(2) Interpreting Cues, such as failing to understand the relevance of data and information overload
and (3) Perceived Ambiguity, including difficulty defining MRPs and conflicting information in the EHR. Ten specific themes were discovered within these macro-categories, providing a comprehensive view of the challenges students confronted. CONCLUSION: Learners experienced significant challenges in detecting MRPs. These challenges were primarily rooted in managing the work-up process, interpreting clinical cues, and handling ambiguous information. The findings suggest a need for more structured scaffolding, repeated case-based practice focused on key cues and new strategies for modeling how to address ambiguity in clinical settings. These modifications may enhance students' clinical reasoning and problem-detection abilities, improving their preparedness for real-world pharmacy practice.