One Third of Pediatric Drug Errors Tied to EHR Usability

Ricki Lewis, PhD

November 06, 2018

Usability of electronic health records (EHRs) contributed to more than a third of medication errors noted in 9000 pediatric patient safety event reports, according to an article published in the November issue of Health Affairs.

Although EHRs eliminate some limitations of paper medical records, such as illegible handwriting, they often introduce other problems, write Raj M. Ratwani, PhD, director of the National Center for Human Factors in Healthcare, MedStar Health, and an assistant professor of emergency medicine at Georgetown University School of Medicine, Washington, DC, and colleagues.

One limitation is "usability," which the researchers define as "the extent to which the technology can be used efficiently, effectively, and satisfactorily" based on system design and customization to specific workflows.

Previous studies have shown that poor usability can contribute to harm among adult patients. Yet children might be particularly vulnerable to harm from poor EHR usability because of physical characteristics that differ from those of adults and their ongoing development.

In 2016, the 21st Century Cures Act asked the Office of the National Coordinator for Health Information Technology (ONC), which oversees EHRs, to voluntarily add certification criteria unique to EHRs used in the care of children.

In the current study, Ratwani and colleagues evaluated whether poor EHR usability contributes to medication dosing errors at two stand-alone pediatric institutions and one adult and pediatric institution. Although each site reported approximately 50,000 patient safety events over the 5-year study period (2012 through 2017), the investigators used an algorithm (a "usability taxonomy") to select 3000 events from each institution likely related to EHR and medication issues.

The investigators coded each case for the specific usability challenge, type of medication error, and whether the event reached and harmed the patient.

The four general usability categories and red flags for EHRs were:

  • System feedback (inappropriate)

  • Visual display (clear, confusing, or cluttered)

  • Data entry (difficult or impossible)

  • EHR workflow and clinician expectations (mismatch)

The analysis used nine medical error types according to the National Medication Errors Reporting Program of the National Coordinating Council for Medication Error Reporting and Prevention (improper dose, wrong strength/concentration, wrong drug, wrong dosage form/technique/route, wrong rate, wrong time, wrong patient, monitoring error, and "other"). The "free text" portion of the EHR indicated whether the error reached the patient.

Among all 9000 patient safety reports, 3243 (36%) had an EHR usability issue that contributed to a medication error, and 609 (18.8%) of those errors reached the patient. Of these, 201 (33%) did not harm the patient nor require monitoring, 109 (17.9%) required monitoring or an intervention to prevent harm, and 20 (3.3%) caused temporary harm. For 279 (45.8%) entries, the consequences were unknown.

The most frequently reported EHR usability challenges were related to system feedback (82.4%), followed by visual display (9.7%), data entry (6.2%), and workflow support (1.7%).

The most common medication error for all three sites was improper dose (84.5%), followed by "other" (5.9%) and wrong time of administration (3.5%). In one extreme case, a physician ordered five times the required dose without an alert from the EHR.

The fact that the general pattern of usability challenges and medication errors were the same across the three sites may reflect a systemic problem that calls for further investigation and finding a solution, the authors suggest. "The most frequent hazards across sites were associated with system feedback, most commonly related to suboptimal clinical decision support or error prevention," they write.

"While 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 researchers conclude. They urge the ONC to include safety with the voluntary certification criteria of EHRs for use with children and add usability measures to assess EHR performance.

A limitation of the study was under-reporting, including both that the authors only considered a pre-selected number of cases per institution and the possibility that not all pediatric patient safety events attributable to EHR errors were reported.

The investigators have reported no relevant financial relationships.

Health Affairs. 2018;37:1752-1759. Abstract

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