Pediatric patients are at risk from electronic health records (EHRs) that do not adequately factor in their needs. Medication dosing is the biggest threat.

• The usability of an EHR affects patient safety.

• Frontline staff may realize the risk more than administrators.

• Efforts to optimize an EHR present an opportunity to address the risk.

Years after the widespread adoption of electronic health records (EHRs), pediatric patients still are at risk from software systems that do not properly account for the needs of younger patients.

One of the most recent reports came from Raj Ratwani, PhD, scientific director and senior research scientist with the National Center for Human Factors in Healthcare at the Medstar Institute for Innovation in Washington, DC. He and his colleagues studied the effect of EHRs on pediatric safety, analyzing 9,000 patient safety reports.

They found the most common usability challenges were associated with system feedback and the visual display, and the most common medication error was improper dosing. Of the 9,000 reports, 36% had a usability issue that contributed to the medication event and 18.8% of those incidents might have resulted in patient harm. (An abstract of the report is available online at: https://bit.ly/2zL28o6.)

“There’s an association between the usability of electronic health records and patient harm events. We focused exclusively on pediatric populations and found that where there were EHR-related medication errors, those can reach the patient,” Ratwani says. “There is building evidence that we have to be aware of EHR usability challenges and how they can affect the patient. In pediatric patients, that is particularly alarming given that they are not as resilient as adults to overcome some of these challenges.”

Don’t Underestimate Impact

Frontline EHR users are aware that the systems pose risks to pediatric patients, he says. Their vigilance and the redundant safety checks built into the healthcare delivery system prevent many instances of potential harm from reaching the patient, Ratwani says.

“From a risk management perspective, there may not be an awareness of how much impact an EHR can have. I think one of the reasons is that when there is an adverse event or near miss, rarely do we look back at the IT system to see how that might have contributed,” he says. “Many people don’t take that system perspective on how the error might have occurred. Instead, they focus on processes and look to blame the individual, when they could be looking for poorly designed technology that contributed to the error.”

Pediatric patients are especially vulnerable to dosing errors, and any EHR system that does not provide adequate safeguards against those errors is problematic, says Robert Hanscom, JD, vice president of business analytics with Coverys, a medical malpractice insurer based in Boston.

“Any time you have scenarios in which specific information is put in and then calculations made on that data, those are fraught with risk. Errors can occur with any patient population, but we have seen that the risk is greater with pediatrics whether you are using an EHR or not, and a poorly designed EHR only increases that risk,” he says.

“Back when these things were done manually, we had terrible errors with pediatric patients suffering great harm. EHRs have helped reduce those kinds of errors, but at the same time EHRs have not been designed to cure all ills. Other vulnerabilities have emerged.”

Many EHRs are simply not designed with the pediatric patient in mind, particularly with regard to dosing, says Ruben Nazario, MD, clinical editor and strategist with Zynx Health, a company in Los Angeles that provides EHR support. He previously worked full-time as a pediatric ED physician, and still works part-time in that role.

“I see that almost every day with EHRs that are not optimized for pediatric patients. They may have some kind of basic safeguards with formularies that specify some medications are more appropriate for adults, and there may be some alerting to maximum dosing,” Nazario says. “But there are still a lot of issues with alerts in terms of usability and when in the work process they provide that information.”

Pediatric safety issues should be assessed and addressed when a hospital or health system is in the process of optimizing the system or changing the EHR product, he says.

“There is a great opportunity now that most providers are through the implementation phase and looking to optimize their EHR systems,” he says.

Hospital leaders are beginning to address the issue more directly and effectively, says Sean Morris, sales director with Digitech Systems, a software company in Greenwood Village, CO.

“Five years ago, the picture was different, but we’ve seen in recent years that a lot of hospital leaders have become more techno-savvy. That may be because we have folks who are a little younger coming up into leadership roles, and it may be that people established in those roles are learning that they need to be better at staying on top of those issues,” Morris says. “We’re seeing a transition in those organizations where they are bringing in groups who understand what components need to work together and individuals who understand the need to address disparity of information across different resources.”


• Robert Hanscom, JD, Vice President of Business Analytics, Coverys, Boston. Phone: (800) 224-6168.

• Sean Morris, Sales Director, Digitech Systems, Greenwood Village, CO. Phone: (866) 374-3569. Email: seanm@digitechsystems.com.

• Ruben Nazario, MD, Clinical Editor and Strategist, Zynx Health, Los Angeles. Phone: (888) 996-9435.

• Raj Ratwani, PhD, Scientific Director and Senior Research Scientist, National Center for Human Factors in Healthcare, Medstar Institute for Innovation, Washington, DC. Phone: (877) 748-3567.