A new Pew Charitable Trusts issue brief outlines twelve instances in which problems with EHR usability may increase the risk of pediatric patient harm.
Problems with EHR usability are notoriously detrimental to provider satisfaction and clinical efficiency, but a new report from Pew Charitable Trusts outlines how clunky interfaces and clinical workflows may also have a negative effect on pediatric patient safety.
“Pediatric patients, for whom dosages may be adjusted by weight or age, are especially susceptible. However, the federal requirements for EHRs do not reflect the differences in care provided to adults and children, and EHRs in use today often do not adequately address specific challenges that emerge in pediatric settings,” stated Pew researchers in the report.
The 21st Century Cures Act prompts ONC to draft voluntary rules for EHR use in pediatric care to reduce potential threats to patient safety.
To inform this policymaking, Pew Charitable Trusts worked with two children’s hospitals and one large mid-Atlantic healthcare system to identify incidents where EHR systems may contribute to drug prescribing and administration errors.
“Researchers at each facility uncovered thousands of such cases from error reports filed internally at the time of the incident,” stated researchers.
“The volume and diversity of issues identified by this research underscore the need for health information technology developers, hospitals, and clinicians to work together to design and implement EHRs, and to rigorously test them before and after deployment in each facility,” researchers continued.
These new regulations may help to resolve gaps in current ONC certification testing, which do not require that EHR systems undergo testing after being customized or implemented.
“Testing requirements for the product design and development phases examine the presence of safety-related features, such as drug allergy alerts, but not whether they are effective,” noted researchers.
Assessing an EHR system’s design, customization and clinical workflow may help to prevent specific incidents that threaten patient safety, including the 12 potential patient safety events Pew described in its report.
First, Pew noted problems with EHR data display may render certain patient health information inaccessible, which can lead to inappropriate drug administration.
“In one instance, a doctor placed an order in a patient’s EHR for amlodipine, a drug that lowers blood pressure,” wrote Pew. “The physician also entered comments in free text, instructing that the medication not be given if the child’s blood pressure was below a certain threshold. However, that field was designed for use by the pharmacy; the EHR view used by the nurse did not display that information.”
“As a result, the nurse did not see the doctor’s note and administered the drug, putting the patient at risk of dangerously low blood pressure,” researchers maintained.
EHR usability problems may also lead to providers incorrectly recording a patient’s weight, which can lead to drug overdoses.
Additionally, poor information display can contribute to a missed dose of antibiotics.
“In one case, the information displayed to the nurse in the EHR failed to show the scheduled administration time for an upcoming dose of the antibiotic gentamicin and did not prompt the nurse to open the order to see that information,” wrote researchers. “This led the nurse to conclude, erroneously, that the dose had been given.”
EHR systems that fail to display automatic medication holds can also lead to missed doses.
Problems with EHR data entry also pose a threat to patient safety. In one instance, an automatic EHR function contributed to a clinician incorrectly scheduling a vaccine.
“For example, in one case, a 4-month-old infant was admitted to the hospital. The EHR’s default settings automatically checked a box to indicate that the patient was greater than 6 months old and generated a vaccination schedule based on this inaccurate data,” wrote researchers.
“Clinicians spotted the EHR’s mistake and did not administer inappropriate vaccines, but the system would neither let them uncheck the box showing the wrong age nor modify the vaccine plan,” they added.
In another instance, a system default setting was associated with a missed organ rejection drug.
“The pharmacy prepared the drug to be given that evening, but the EHR defaulted the administration time to the next morning and the patient received the medicine half a day late, elevating the risk for rejection of the transplant,” researchers explained.
Additionally, hidden medication order settings can lead to a lapse in care, while alert failures can lead to clinicians missing information about a documented drug allergy.
Researchers also indicated an incident in the report in which auto-verification of a medication contributed to a delay in its administration.
“In one case, a clinician ordered a patient to receive the antibiotic ampicillin. The EHR incorrectly processed the medication as if it were in the dispensing machine,” wrote researchers. “Thus, the pharmacy was not prompted to prepare the drug, and the clinician was not alerted. After a two-hour delay, the pharmacy was notified of the error; that delay could have led to a serious infection.”
In another case, an erroneous EHR setting automatically discontinued an medication for a patient who still needed it, which may have increased that patient’s risk of death.
Finally, researchers cited two instances in which problems with EHR clinical workflows contributed to a higher risk for patient harm.
In one instance, EHR workarounds led to duplicative chemotherapy treatments for a patient. In another, physicians were delayed while attempting to deliver emergency care to a newborn because they were unable to adjust their clinical workflow to account for the care.
“For example, the EHR in one hospital would not allow clinicians to create a record for newborns unless staff first entered the child’s weight and Apgar score, a composite measure of health indicators,” wrote researchers. “This slowed treatment for a baby girl who required emergency care before an Apgar score could be obtained.”
Developing rigorous tests to assess safety-related EHR usability features throughout the EHR lifecycle may help to prevent these and other incidents in the future.
Date: April 26, 2019
Source: EHR Intelligence