In an analysis of 9,000 pediatric patient safety reports from three healthcare organizations, researchers found that 36 percent of the reports were related to EHR (electronic health record) usability issues.
The research, published in the November issue of Health Affairs, and led by Raj Ratwani, Ph.D., director of the National Center for Human Factors in Healthcare, Washington, D.C.-based MedStar Health, and others, aimed to further understand the specific issues around why pediatric populations are uniquely vulnerable to the usability and safety challenges of EHRs particularly those related to medication.
To understand specific usability issues and medication errors in the care of children, the researchers analyzed 9,000 patient safety reports, over a five-year span, from three different healthcare institutions—two stand-alone pediatric institutions and one adult and pediatric institution that used Epic and Cerner EHRs (two institutions used Epic, and one used Cerner)—that were likely related to EHR use.
Of the 9,000 reports, 3,243 (36 percent) had a usability issue that contributed to the medication event, and 609 (18.8 percent) of the 3,243 might have resulted in patient harm, the researchers found.
“The general pattern of usability challenges and medication errors were the same across the three sites. The most common usability challenges were associated with system feedback and the visual display. The most common medication error was improper dosing,” the research revealed.
The researchers noted in the study that pediatric patients are uniquely vulnerable to EHR usability and safety challenges because of different physical characteristics, developmental issues, and dependence on parents and other care providers to prevent medical errors. For example, they offered, lower body weight and less developed immune systems make pediatric patients less able to tolerate even small errors in medication dosing or delays in care that could be a result of EHR usability and safety issues.
Although the Office of the National Coordinator for Health Information Technology (ONC) has policies to promote usability—such as requiring system developers to incorporate feedback from clinicians into software design and development and mandating the testing of twelve high-risk EHR functions that are primarily related to medication—the researchers noted that these policies have not made a distinction between adult and pediatric populations. However, the 21st Century Cures Act of 2016 requires ONC to establish new voluntary criteria unique to EHRs used in the care of children.
For this research, the 9,000 reports—3,000 from each site—were reviewed to verify whether the events were related to the EHR and medication; determine whether EHR usability contributed to the event and, if it did, identify what the specific usability challenge was; identify the type of medication error; and identify whether the event reached the patient.
Of the 9,000 patient safety event reports that were collected, 56 percent were confirmed as being related to both the EHR and medication. Of these 64 percent had a usability issue as a contributing factor to the safety event, which amounts to 36 percent of the total 9,000 reports analyzed.
Of the 3,243 reports (36 percent) that had usability as a contributing factor, 19 percent reached the patient. Of these, 33 percent did not cause harm and did not require monitoring, 18 percent required monitoring or an intervention to prevent harm, 3 percent resulted in temporary harm, and the consequence was unknown for 46 percent, the researchers revealed.
One example of a usability issue that caused some harm was when a when a physician ordered five times the recommended dose of a medication without receiving an alert from the EHR, although the prescribed dose was outside the recommended range. Both vendor design and development, as well as implementation and customization, may be contributing to the challenges associated with system feedback, the researchers stated.
“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 Leapfrog [computerized provider order entry simulation] tool, which assesses clinical decision support functionality, is one example of the types of tools that could improve the safety of implemented EHR products,” they said.
The researchers concluded, “To better prevent usability-related medical errors, the ONC could include safety as part of the voluntary certification criteria of EHRs for use with children and implement usability-related measures to assess EHR performance. Vendors and providers should use rigorous test-case scenarios based on realistic clinician tasks. Finally, the Joint Commission should assess EHR safety as part of its hospital accreditation program. The implementation of approaches such as these is needed to reduce patient harm related to EHR use.”
