The Journal of Pediatrics
Volume 152, Issue 2 , Pages 153-155, February 2008

Technology and Pediatric Patient Safety: What to Target is the Dilemma

  • Fiona Howard Levy, MD

      Affiliations

    • Corresponding Author InformationReprint requests: Fiona Howard Levy, MD, Children’s Medical Center of Dallas, 1935 Motor St, Dallas, TX 75235.

Department of Pediatrics, University of Texas Southwestern Medical School, Dallas, Texas

Article Outline

Abbreviations: CPOE, Computerized physician order entry, EHR, Electronic health record, HIT, Health information technology, IOM, Institute of Medicine

 

Most pediatricians are familiar with the Institute of Medicine’s (IOM) landmark 1999 report, To Err is Human,1 which estimated that between 44,000 and 98,000 people die in America as the result of medical error. Although the exact number of injured and dead patients has been challenged,2 little doubt remains that a patient safety crisis exists within healthcare. Furthermore, pediatric patients are not exempt from either medical errors or their potential for harm.3, 4, 5

See related articles, p 214, p 219, and p 225

Error, defined as “the failure of a planned action to be completed as intended or use of a wrong plan to achieve an aim,”5 often goes undetected and under-reported and has therefore been very difficult to quantify.6 It is when error occurs in association with an adverse event, harm/injury derived as the result of medical care, that it is most easily detected. Important exceptions to this may be the medication7, 8 and laboratory processes9, 10 for which an increasing number of studies report estimates of error, adverse events, and near misses. Depending on the study cited and the method of event detection and measurement, it is estimated that hospitalized children are subjected to adverse events in 1% to 3% of hospitalizations, and preventable adverse events occur in 0.6% of pediatric hospitalizations.11, 12 On the basis of recent estimates of 3.4 million pediatric discharges,13 this translates into >20,000 hospitalized children harmed as the result of medical error each year in the United States.

The technologies available to enhance patient safety are very broad in scope. In addition to bar-coding and electronic prescribing tools, there are clinical decision support systems, robots, smart infusion pumps and devices, automated medication dispensing systems, radio-frequency identification devices, and the electronic medical record. Many of these electronic clinical information systems, when considered together, are referred to as an electronic health record (EHR) and contribute to the more global health information technology (HIT).14 Lack of consistent nomenclature, however, impedes classification of HIT. On the basis of IOM recommendation, 2 goals of the successfully implemented EHR should be to improve patient safety and to support the delivery of effective patient care. Core functionalities for an EHR, therefore, include health information and data, results management, order entry/management, decision support management, electronic communication and connectivity, and, finally, reporting capabilities.14

As confirmation of ever-increasing efforts to improve pediatric patient safety, this issue of The Journal features 2 reports detailing implementation of technology-based applications to reduce medical error in pediatric patients. In 1 study, Hayden et al15 describe a computer-assisted bar coding system to reduce the rate of laboratory specimen labeling error in a pediatric hospital. In a separate report, Jani et al16 describe the application of an electronic system to reduce the number of prescribing errors in an ambulatory pediatric nephrology practice. Individually, each article highlights different benefits that can be gained from the technological applications to reduce medical error. When considered together, they underscore an important strategic issue: How do we decide the focus and boundaries of HIT solutions? Both interventions described in this issue were targeted and therefore of limited scope and, thus, impact. For instance, the intervention reported by Hayden15 did nothing to prevent unnecessary testing, or assist providers in ensuring that screening studies be successfully ordered.

As we manage the scope of technology solutions, the use of HIT should be driven by pediatric-specific safety risks. These include communication barriers that occur both as a consequence of the varying language skills/developmental stages of our patients and the need to communicate with both the patient and a changing variety of accompanying caregivers. Further, we must provide therapies, such as immunizations and injury prevention advice, which constantly vary with the age/development of the patient. Although a comprehensive electronic medical record with accompanying medication ordering and decision support systems would appear to be very desirable, a recent survey demonstrates limited adoption of such technology.17 This may be caused by a myriad of reasons, including the barriers to the use of an EHR during patient encounters,18 the occurrence of unanticipated errors in the processes of information management and communication,19 the need for pediatric-specific EHR systems,20 and substantial costs.

In addition, we are acutely challenged in pediatrics because both medication errors and their potential to cause harm are more prevalent compared with adult patients.2, 7 This is likely caused by several factors, including the need for weight-based/non-standard dosing and formulations and increased off-label drug use. Many have explored technologies to decrease medication errors. Reviews22 and individual studies23 detail both the benefits and the unforeseen risks following the implementation of 2 linked components of the EHR, computerized physician order entry (CPOE), and clinical decision support tools. CPOE is a tool that requires providers to enter orders, such as prescription drugs or laboratory tests, into a computer system (e-prescribing), and clinical decision support systems assist care providers by offering “best practice” recommendations combining information about the individual patient and a database of recommended procedures. In this issue of The Journal, Jani et al16 highlight the application of CPOE (with only basic clinical decision support) to reduce ordering errors, 1 of the largest contributors to medication error with administration and transcription.21 However, their technology intervention was uncoupled from clinical information, limiting the types of errors it would likely impede. The American Academy of Pediatrics Clinical Council on Information Technology released a policy statement24 in support of electronic prescribing that recommends CPOE be implemented with, at a minimum, pediatric-specific clinical decision support and ideally as part of a larger EHR solution.

As we try to understand the best use of HIT to support patient safety, it is prudent to understand how it can contribute to, or possibly direct, compliance with the broader system-based healthcare improvement recommendations made by the IOM1 and others.25 Three of the many recommendations include understanding the fallibility of humans and improving the systems that support them, redesigning the healthcare delivery system to be less fragmented with improved communication and availability and transparency of information, and creating and implementing standardized error reporting so we can begin to have accurate and accessible data on which to base improvement efforts. There is increasing evidence to suggest that the EHR not only supports the broad-based availability of accurate and timely medical information, but that it also allows the automated and often real-time detection of errors and adverse events,26, 27 therefore not only allowing for the collection of data, but more importantly for the intervention to improve patient outcome. Although many of the HIT solutions create the opportunity to improve human performance and prevent error, they will only be successful when enacted in a well planned, staged effort.

Finally, as we consider the cost of HIT, the financial burden is not solely related to the technologic application and equipment. To understand true costs, the necessary training, the transient loss of productivity, and the likely need for large-scale organizational process change also need to be considered.25 The literature is conflicted about HIT cost/ benefit balance and return on investment overall; in pediatrics, there is no evidence supporting a purely financial benefit with HIT.28, 29 However, as the practices of pay-for-performance and non-payment for error/adverse event-associated costs grow in the world of reimbursement, the balance of cost/benefit may shift in favor of increased HIT investment.

The reports in this issue of The Journal by Hayden et al15 and Jani et al16 both serve to demonstrate the success of technology in reducing medical error. Although both are positive and promising studies, they focus on the application of technology to a small portion of a larger, more complicated process. Review of the safety medical literature demonstrates both variability of success and some unintended consequences that result when we underestimate or under-prepare for system complexity. It is, perhaps, not unreasonable to suppose that as we continue to advance in experience and evidence, the HIT solutions of choice will best serve when they have been designed to address the holistic process of care and not single fragmented event (s).

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References 

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PII: S0022-3476(07)01048-7

doi:10.1016/j.jpeds.2007.11.002

Refers to article:

  • Electronic Prescribing Reduced Prescribing Errors in a Pediatric Renal Outpatient Clinic , 19 November 2007

    Yogini Hariprasad Jani, Maisoon Abdullah Ghaleb, Stephen D. Marks, Judith Cope, Nick Barber, Ian Chi Kei Wong
    The Journal of Pediatrics February 2008 (Vol. 152, Issue 2, Pages 214-218)

  • Computer-Assisted Bar-Coding System Significantly Reduces Clinical Laboratory Specimen Identification Errors in a Pediatric Oncology Hospital , 26 October 2007

    Randall T. Hayden, Donna J. Patterson, Dennis W. Jay, Carl Cross, Pamela Dotson, Robert E. Possel, Deo Kumar Srivastava, Joseph Mirro, Jerry L. Shenep
    The Journal of Pediatrics February 2008 (Vol. 152, Issue 2, Pages 219-224)

  • Risk Factors in Preventable Adverse Drug Events in Pediatric Outpatients , 19 November 2007

    Stephanie O. Zandieh, Donald A. Goldmann, Carol A. Keohane, Catherine Yoon, David W. Bates, Rainu Kaushal
    The Journal of Pediatrics February 2008 (Vol. 152, Issue 2, Pages 225-231)

The Journal of Pediatrics
Volume 152, Issue 2 , Pages 153-155, February 2008

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