What's the cause of 50% of pediatric safety errors?

Safety errors happen in medicine and, when they do, the results can be tragic. Although human error is one factor, electronic health records (EHRs) also may play a role-especially when it comes to medication errors.

A new study published in Health Affairs investigated what role EHRs play in safety challenges in the pediatric setting, and what might contribute to these events. Researchers investigated 9000 patient safety reports between 2012 and 2017 from 3 different healthcare institutions and found that more than half the errors recorded were related to both EHR function and medication.

“The usability of EHRs can introduce patient safety risks, and during the medication process these usability issues can result in medication errors that reach the patient,” says Raj Ratwani, PHD, director of the National Center for Human Factors in Healthcare and lead author of the report. “The biggest usability issues are related to system feedback and the visual display. System feedback issues are when the EHR does not provide the right feedback given the context of the patient.”

For example, Ratwani says EHRs may not provide appropriate alerts when a medication is prescribed to a patient that has a known allergy to that medication. Visual display issues occur when the EHR display is cluttered or confusing.

“These display issues can make it difficult to enter the appropriate medication information leading to errors,” Ratwani says. “Across the board, the most common type of medication errors were improper dose errors, commonly overdoses.”

Usability issues

Ratwani’s study found that 36% of these reports had EHR usability issues that contributed to medication errors, and 18.8% may have resulted in patient harm. Usability refers to how efficiently and effectively an EHR system can be used, and the research team found that most errors were associated with system feedback and visual displays, with medication dosing being the most common error.

Although the Office of the National Coordinator for Health Information Technology (ONC), a federal agency that oversees EHRs, has policies to promote usability including involving clinicians in the design and function of EHRs, few policies make a distinction between adult and pediatric populations. This can present particular challenges in the pediatric population when it comes to medication dosing, according to the report.

Medication errors

Across the study population, the research team found that 84.5% of medication errors were attributed to improper dosing, and 3.5% were related to improper timing such as missed doses, according to the researchers.

“One example of an event in this category occurred when a physician ordered 5 times the recommended dose of a medication without receiving an alert from the EHR, although the prescribed dose was outside the recommended range,” the report notes. “Both vendor design and development, as well as implementation and customization, may be contributing to the challenges associated with system feedback. To address this systemic problem, vendors and providers should consider developing more comprehensive design guidelines and use generalizable tools to assess usability and safety.”

The research team notes that while EHRs may have led to improvements in care delivery, it’s worth another look because one-fifth of the reported events studied reached the patients and 129 caused some type of harm.

“Whereas EHRs have improved care and safety under certain circumstances, these findings suggest that thousands of patients may be put at risk because of usability challenges that stem from the design, implementation, customization, or use of this technology,” the report points out.

What lies ahead

Moving forward, the research team suggests that healthcare facilities and EHR vendors need to put more focus on safety alerts and how dosing information is presented to clinicians. The Joint Commission also can play a role, the report suggests, adding an assessment of EHR safety to its hospital accreditation program.

On the micro level, Ratwani says clinicians should trust their EHR system, but verify that what they are seeing is what they intended to order. “Always check information being entered in and viewed in the EHR to ensure accuracy,” he says.

Clinicians also can identify any areas with potential safety problems and communicate their orders to frontline staff, or larger problems to hospital leaders.

“When placing high risk medication orders, always verbally communicate to confirm what is entered and seen in the EHR. If there are known risk areas, talk to your staff about these issues to raise awareness,” Ratwani says. “Also, report known issues. If you suspect that some aspect of the EHR may introduce safety issues, report on these items.”

Ratwani says he hopes the report will raise awareness and elicit change to EHR usability to reduce these safety events.

“Our hope is that this report will raise awareness of EHR usability and safety challenges for EHR developers, frontline clinicians, and policymakers,” he says. “The EHR developers should work with provider organizations to improve usability and safety and reduce adverse patient outcomes. Frontline clinicians should recognize the risks of EHRs and monitor for safety hazards. Policymakers should ensure that the voluntary pediatric certification program, being developed by the Office of the National Coordinator, includes usability and safety.”