12 patient safety risks linked to EHR usability

A Pew Charitable Trust report details how challenges can lead to drug errors that can jeopardize young patients.

12 patient safety risks arising from EHR usability problems

Digital records systems have created unforeseen safety risks, sometimes contributing to serious mistakes in treatment, and that’s particularly true for pediatric patients, contends researchers for the Pew Charitable Trusts. These unintended consequences can be devastating for young patients, especially when they involve medications—pediatric patients often have dosages adjusted depending on their weights or ages. The researchers found that current EHR systems generally don’t reflect the differences in care provided to adults and children. In fact, “EHRs in use today often do not adequately address specific challenges that emerge in pediatric settings,” the report notes.

To understand the scope of these problems, researchers from Pew worked with two children’s hospitals and one large mid-Atlantic healthcare system to identify and investigate incidents in which EHRs reportedly contributed to drug prescribing or administration errors that jeopardized safety for pediatric patients. These issues underscore the need for health information technology vendors, hospitals and clinicians to work together to design and implement EHRs, and to test them before and after deployment.

Examples of EHR usability-related medication safety events

Usability challenges fall into four broad categories:
• Information display: EHRs may display information in confusing ways, or data may be hard to find or missing.
• Difficult data entry: Challenges here may cause delays for orders and lead to clinician workarounds.
• System feedback: In some situations, EHRs may not communicate that an action has been taken, such as when a patient has already received a medication.
• Workflow support: Problems may arise when clinicians must share information or tasks with others.

Case 1: Inaccessible information leads to inappropriate drug administration

EHRs may give clinicians multiple free-text fields where they can enter notes to other care team members—but staff may not know which of the fields teammates can access. In one instance, a doctor placed an order in a pediatric patient’s EHR for amlodipine, a drug that lowers blood pressure. 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, and the view of the EHR 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.

Case 2: Patient experiences a drug overdose because of an error in weight entry

Some EHRs allow measurement documentation in U.S. units, such as pounds and inches, instead of the metric units traditionally used in medicine. In one case, a clinician entered a child’s weight in pounds when the EHR was configured to receive weight in kilograms. This effectively doubled the child’s actual weight, and the patient received twice the appropriate acetaminophen dose. To avoid this, EHRs should clearly specify the appropriate units of measurement and flag when a potentially erroneous value has been entered.

Case 3: Poor information display contributes to a missed antibiotic dose

EHRs typically can list all past and scheduled future drug doses, including the time of administration. 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. This led the nurse to conclude, erroneously, that the dose had been given. In addition, the EHR did not subsequently indicate a missed dose. This omission could have contributed to an uncontrolled infection.

Case 4: Display problems with automatic medication holds cause missed dose

EHRs can allow clinicians to enter medication orders ahead of time for different phases of pre- and post-surgical care. When the patient’s location within a hospital changes, record systems can automatically place holds on future orders—staff at the receiving location must remove the holds so the drug can be prepared and delivered. However, usability flaws can lead clinicians to overlook these holds and associated care instructions. In one case of a patient unexpectedly transferred back to an operating room, the EHR held a medication order for an antifungal medication, and the clinicians were unaware of the held dose, putting a patient at risk for a prolonged infection.

Case 5: Automated EHR function enters an Incorrect vaccine schedule

EHRs can have built-in processes, such as a standard vaccination schedule based on date of birth. These features can create safety risks if clinicians are unable to override them. 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 more than 6 months old and generated a vaccination schedule based on this inaccurate data. Clinicians spotted the EHR’s mistake and did not administer inappropriate vaccines. These types of errors could lead to harm since physicians and nurses treating the patientin the future could rely on the information in the EHR.

Case 6: A time change was associated with a missed organ rejection drug

EHRs can allow clinicians to order recurring doses of a drug at specific times or intervals. System defaults, however, may supersede these instructions without staff realizing it. In one case, a clinician prescribed an immunosuppressant medication used to prevent organ rejection in kidney, liver and heart transplant patients and directed it to be administered every 12 hours. 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.

Case 7: Hidden medication order settings contribute to a lapse in care

EHRs can offer preset choices for the duration of a prescription, such as five, 10 or 30 days, to help calculate the quantity of a drug to be dispensed. However, in one case, a provider intended to prescribe indefinite antiviral therapy for a transplant patient, but accidentally selected the EHR’s preset 30-day, “no refills” prescription order. The error was detected at a follow-up visit after a five-day treatment lapse that increased the risk of infection and transplant rejection.

Case 8: An EHR fails to alert clinicians to a documented drug allergy

EHRs are designed to record patient drug allergies and alert clinicians when a prescription order may risk an adverse reaction. Since clinicians can grow dependent on these alerts, it is important for EHRs to flag any possible allergies. This can be a challenge for medications prescribed as part of an order set. For example, an anesthesiologist ordered prochlorperazine, a medication used to treat nausea and vomiting, as part of an order set for a patient whose record noted an allergy to the drug. Yet, the EHR did not provide an alert for the medication when listed as part of an order set, and the order was subsequently filled.

Case 9: Auto-verification of a medication contributes to administration delays

Some EHRs can connect with automated medication dispensing machines that give hospital staff outside of the pharmacy access to common medications. However, communication problems between these tools and EHRs can delay care. 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—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—the delay could have led to a serious infection.

Case 10: A medication is discontinued automatically in the EHR

EHRs can list drugs that are either intended to be administered indefinitely or set to be discontinued after a set duration. However, clinicians may not be able to clearly distinguish between the two types of orders in EHR system interfaces. In one event, a clinician in the emergency department ordered antibiotics for a patient with suspected sepsis. After the patient was admitted to the hospital from the emergency department, another physician reviewed the active orders and saw the patient appeared to be on the correct antibiotics—but later, the physician noticed that the medications had been automatically discontinued. The physician reordered the antibiotics, but the delay could have increased the risk of death.

Case 11: Workarounds arising from EHR limitations cause problems

Clinicians use EHRs to document many facets of care, but some systems may lack the necessary features to treat patients with complex medical needs. In these cases, clinicians may document care both in the EHR and by other means, including on paper. In one hospital, oncologists use a combination of the EHR and a paper chart to manage their patients’ chemotherapy. When a patient received a scheduled dose of vincristine, a powerful cancer medication, the treatment was documented in the EHR but not on the paper chart. When reviewing the paper chart, clinicians concluded that the patient had missed the scheduled treatment and administered an additional and unnecessary dose without consulting the EHR.

Case 12: Inability to adjust workflow holds up newborn care

To complete some EHR functions, clinicians must enter data in specific fields for a record to be created or orders to be processed. In some situations, those requirements can delay 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. This slowed treatment for a baby girl who required emergency care before an Apgar score could be obtained. As a result, clinicians could not order blood for an emergency transfusion. They eventually placed the order through her twin brother’s record, which delayed the transfusion and introduced risks that the blood would be given to the wrong infant.

How to correct these issues

Pew researchers suggest the following critical steps to ensure better performance of EHRs for pediatric patients:

ONC has an opportunity to address this discrepancy when implementing the 21st Century Cures Act. As part of regulations for the certification of EHRs used in the care of children, the agency could include safety-related requirements to reduce the likelihood that these types of errors occur. For example, ONC can encourage the testing of systems for safety by pediatricians and other clinicians who provide care to children.

Similarly, as EHR vendors and hospitals evaluate systems, new features, or site-specific customizations, they should use more robust and rigorous tests to detect and prevent safety-related challenges, such as after the implementation of systems in hospitals.

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