Additional Safety Measures Recommended After Study Finds EHR Usability Issues Pose Risk to Children

November 5, 2018

WASHINGTON, DC —Electronic health records (EHRs) may present a significant risk to the health and safety of children, according to a new study published today in the November issue of the health policy journal Health Affairs. Of 9,000 analyzed pediatric reports, more than one third described a medication error that was related to EHR usability. The findings emerged from the analysis of pediatric patient safety event reports that were likely to be related to EHRs and medication, gathered from three healthcare systems. The most common type of medication error associated with EHR usability was an over- or under dose.

The report, “Identifying Electronic Health Record Usability and Safety Challenges in Pediatric Settings,” was based on a study conducted by MedStar Health’s National Center for Human Factors in Healthcare, in collaboration with Children’s Hospital of Philadelphia and Children’s Hospital of Wisconsin, and with funding from the Pew Charitable Trusts and the Agency for Healthcare Research and Quality.

Of the 9,000 reports, 3,243, or 36 percent, were confirmed to have an EHR usability issue that affected the medication process. In 609 cases, or 18.8 percent of the 3,243, the EHR-related medication error reached the patient, and many of these cases might have resulted in harm.

Based on these findings, the authors recommend that the federal Office of the National Coordinator for Health Information Technology (ONC), which oversees EHRs, should include safety as part of a pediatric-focused voluntary certification program, and that rigorous test-case scenarios based on realistic clinical tasks should be employed in all phases of EHR development and implementation. The authors also conclude that the Joint Commission should assess EHR safety as part of its hospital accreditation program.

EHR usability issues have been previously documented by the National Center for Human Factors in Healthcare and were reported in a study published by the Journal of the American Medical Association in March 2018. In the current study, researchers sought to put the risk in context of one of the most vulnerable patient populations – children – whose unique needs were recognized in the 21st Century Cures Act of 2016 that calls for the federal government to establish new criteria for designing EHRs used in the care of children.   

Raj Ratwani, PhD, director of MedStar’s Human Factors Center and a lead researcher and author, said, “While there are many benefits to EHRs, usability is a recognized challenge and can have safety implications. We sought to identify the specific types of EHR usability issues and associated medication errors in pediatric settings. These new findings reinforce precisely why it’s imperative for the ONC to act swiftly to ensure safety is part of the EHR voluntary certification program. One patient harmed is one too many, and we all have a heightened responsibility to protect all patients, especially children.”

The report states, “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, 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.”

The researchers found these usability issues to be the most common in the reports analyzed:

  • System feedback (82.4 percent), such as failure of a critical alert being triggered when an unusually large medication dose was ordered, or the system defaulting to a different date or time than ordered for administering the medication, resulting in a missed dose
  • Visual display (9.7 percent), defined as confusing or cluttered information display
  • Data entry (6.2 percent), defined as difficult or impossible entry of information
  • Workflow support (1.7 percent), defined as a mismatch between the EHR workflow and expectations of the clinician

In addition to Dr. Ratwani, the study authors are Erica Savage, Amy Will, and Allan Fong, of the National Center for Human Factors in Healthcare; Dean Karavite, Naveen Muthu, and Robert Grundmeier of Children’s Hospital of Philadelphia; A. Joy Rivera and Cori Gibson of Children’s Hospital of Wisconsin; and Don Asmonga, Ben Moscovitch, and Josh Rising of the Pew Charitable Trusts.

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About the MedStar Health National Center for Human Factors in Healthcare The MedStar Health National Center for Human Factors in Healthcare occupies a unique position in the United States as the largest human factors program embedded within a healthcare system. It brings together human factors scientists, systems safety engineers, health services researchers, clinicians, and other experts to create a safer and more efficient healthcare environment through four core services in research, usability, safety advisement, and education. The center is part of the MedStar Institute for Innovation and is also affiliated with the MedStar Health Research Institute and MedStar Institute for Quality and Safety. MedStar Health, the parent organization, is the largest not-for-profit healthcare provider in the Maryland and Washington, D.C., region, with 10 hospitals and an extensive ambulatory services network, and is the medical education and clinical partner of Georgetown University.  

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