Presentation
A qualitative analysis of EHR prescribing workflows for weight-based dosing in pediatric populations
DescriptionBackground: Pediatric clinicians provide care in an increasingly complex healthcare environment, which can increase opportunities for preventable harm.(Kirkendall et al., 2012; Walsh et al., 2014) Children are at greater risk of harm compared to adults because minor errors in treatments such as medications can have disproportionately harmful effects on children, making it important to institute weight-based dosing (WBD).(Commission, 2021; Kaushal et al., 2004) Accurate prescribing of weight-based medications requires synthesizing a host of information: prescribers must know pertinent details about the patient, their medical condition, medication dosing, medication formulation, and how to apply sophisticated rounding strategies to avoid under- or over-dosing.(Russell et al., 2022) Although electronic prescribing can help reduce some errors associated with WBD, a mismatch between EHR design and clinician workflows can also contribute to errors. The objective of our study was to investigate the workflow and workload involved in prescribing, dispensing, and administering weight-based medication in pediatric populations. This work is the first step in a research initiative to develop a standardized checklist that can ultimately be used by a wide variety of stakeholders to assess EHR safeguards around prescribing weight-based medications for pediatric patients.
Methods: Semi-structured interviews were conducted with 18 participants (n=7 physicians; n=2 nurses; n=6 pharmacists; n=6 health information technology [health IT] experts, wherein three health IT experts had overlapping clinical roles and were categorized as both) with experience in using health IT for WBD and representing nine healthcare institutions and one research institute. Interview guides were developed iteratively by a multidisciplinary team, including human factors engineers, physicians, and health researchers. Topics discussed included workflows and special circumstances for prescribing, dispensing, or administering medications, tools to combat errors, and opportunities for improvement.
Convenience sampling was used to recruit participants via word of mouth through clinician and research partners across a wide variety of clinical sites and geographic locations. Virtual interviews lasting approximately 60 minutes occurred in July and August 2023. A minimum of two interviewers (LS, GF, SK) conducted each interview, with one researcher acting as the primary interviewer and the other as note taker. Interviews were recorded and transcribed. Data analysis occurred concurrently across participant stakeholder groups between three team members (GF, AJ, and LS). Researchers utilized open coding to segment data into discrete statements before identifying themes. Coding discrepancies were resolved by discussion and consensus.
Results: The tasks of prescribing, dispensing, and administering medications were described as specialty-specific, in which prescribing was led by physicians (with pre-ordering tasks completed by nurses or other hospital staff members), dispensing by pharmacists, and administering by nurses. Two participants reported that the ordering process is conducted primarily by resident attendees at their institutions. Exceptions to role-specific practices occurred only in emergency situations in which there was not enough time to engage in the typical workflow.
- Prescribing workflow (pre-ordering and ordering):
The prescribing workflow comprised two main tasks: pre-ordering, and ordering. The pre-ordering workflow included gathering patient information including weight and chief complaint, usually collected by nurses or other hospital staff. The ordering workflow including selecting the medication and orders for administration, computing calculations for WBD based on the patient’s weight and medication route (occasionally completed using calculator tools within the EHR), and conducting double checks of the order for dose based on weight, especially when drafted by residents. In circumstances in which prescribers were reviewing patient information within the EHR such as weight or age, the majority relied on their clinical training to assess the accuracy of the data.
Participants mentioned substantial challenges within prescribing, including challenges with ordering the intended route, frequency, or dose of medication, capturing an accurate weight, differentiating between pediatric and adult patients, manual calculations for WBD, misplaced decimal points, entering data in the wrong field, and lack of expertise. Other challenges in the pre-ordering and ordering stages were attributable to device errors (e.g., faulty EHR systems, rounding errors, and challenges with imperial vs. metric system), and system errors (e.g., lack of safety nets within the healthcare system, lack of order visibility for providers after it is sent to the pharmacy), and those related to the patient (e.g., obtaining weight and height information from a patient who is unwilling or otherwise unable to be measured in the moment, such as an emergency arrival).
- Dispensing workflow:
Participants who described the medication dispensing process for WBD reported interacting with the EHR for all components of the medication verification process. At the stage of medication preparation, the dispensing workflow comprised of closely reviewing information pertinent to weight-based including the appropriateness of the medication and dosing based on patient information (e.g., actual weight, dosing weight, etc.) and reviewing clinical information such as labs and patient history. Challenges with dispensing included inability to capture weight in emergency situations, selecting the wrong dose, inability to concurrently see the medication data with the relevant patient information, and the EHR not clearly differentiating between pediatric vs. adult patients.
- Administration workflow:
Individuals who described the administration process for WBD reported using the EHR primarily to verify medication information (e.g., dose, frequency). One individual reported personally double checking the math for weight-based medications.
Participants also spoke of challenges within the administration stage, including use of the wrong administration device, incorrect dose is drawn up, distractions/interruptions, delays in administration due to preparation requirements and lack of supplies, and device errors (e.g., pump-related challenges).
- EHR changes to mitigate WBD errors
Participants suggested many changes to mitigate these errors, including dynamic information checking during the ordering process, toggled displays, alterations to existing alert structures, and alterations to order sets. Participants also highlighted the need for human factors-based principles through the use of color to flag pediatrics vs. adult populations within the EHR, clear displays of trended weight data over time, and different fonts/colors to clarify the purpose of specific alerts.
Discussion: This qualitative analysis of prescribing, dispensing, and administering practices among healthcare professionals revealed critical insight to the dynamic practice of weight-based dosing for pediatric populations. We found substantial challenges in obtaining and synthesizing information to accurately prescribe, dispense, and administer weight-based medications in pediatric patients. Healthcare providers often had to manually perform tasks required checking, such as verifying patients’ weight and height, or decimal points. These tasks can impose high burden on providers and suggests a gap in the design of current EHR systems in safeguarding against such errors. Changing or adding safeguards will further enforce the ultimate goal of having system capabilities that protect patients from harm due to WBD errors.
Methods: Semi-structured interviews were conducted with 18 participants (n=7 physicians; n=2 nurses; n=6 pharmacists; n=6 health information technology [health IT] experts, wherein three health IT experts had overlapping clinical roles and were categorized as both) with experience in using health IT for WBD and representing nine healthcare institutions and one research institute. Interview guides were developed iteratively by a multidisciplinary team, including human factors engineers, physicians, and health researchers. Topics discussed included workflows and special circumstances for prescribing, dispensing, or administering medications, tools to combat errors, and opportunities for improvement.
Convenience sampling was used to recruit participants via word of mouth through clinician and research partners across a wide variety of clinical sites and geographic locations. Virtual interviews lasting approximately 60 minutes occurred in July and August 2023. A minimum of two interviewers (LS, GF, SK) conducted each interview, with one researcher acting as the primary interviewer and the other as note taker. Interviews were recorded and transcribed. Data analysis occurred concurrently across participant stakeholder groups between three team members (GF, AJ, and LS). Researchers utilized open coding to segment data into discrete statements before identifying themes. Coding discrepancies were resolved by discussion and consensus.
Results: The tasks of prescribing, dispensing, and administering medications were described as specialty-specific, in which prescribing was led by physicians (with pre-ordering tasks completed by nurses or other hospital staff members), dispensing by pharmacists, and administering by nurses. Two participants reported that the ordering process is conducted primarily by resident attendees at their institutions. Exceptions to role-specific practices occurred only in emergency situations in which there was not enough time to engage in the typical workflow.
- Prescribing workflow (pre-ordering and ordering):
The prescribing workflow comprised two main tasks: pre-ordering, and ordering. The pre-ordering workflow included gathering patient information including weight and chief complaint, usually collected by nurses or other hospital staff. The ordering workflow including selecting the medication and orders for administration, computing calculations for WBD based on the patient’s weight and medication route (occasionally completed using calculator tools within the EHR), and conducting double checks of the order for dose based on weight, especially when drafted by residents. In circumstances in which prescribers were reviewing patient information within the EHR such as weight or age, the majority relied on their clinical training to assess the accuracy of the data.
Participants mentioned substantial challenges within prescribing, including challenges with ordering the intended route, frequency, or dose of medication, capturing an accurate weight, differentiating between pediatric and adult patients, manual calculations for WBD, misplaced decimal points, entering data in the wrong field, and lack of expertise. Other challenges in the pre-ordering and ordering stages were attributable to device errors (e.g., faulty EHR systems, rounding errors, and challenges with imperial vs. metric system), and system errors (e.g., lack of safety nets within the healthcare system, lack of order visibility for providers after it is sent to the pharmacy), and those related to the patient (e.g., obtaining weight and height information from a patient who is unwilling or otherwise unable to be measured in the moment, such as an emergency arrival).
- Dispensing workflow:
Participants who described the medication dispensing process for WBD reported interacting with the EHR for all components of the medication verification process. At the stage of medication preparation, the dispensing workflow comprised of closely reviewing information pertinent to weight-based including the appropriateness of the medication and dosing based on patient information (e.g., actual weight, dosing weight, etc.) and reviewing clinical information such as labs and patient history. Challenges with dispensing included inability to capture weight in emergency situations, selecting the wrong dose, inability to concurrently see the medication data with the relevant patient information, and the EHR not clearly differentiating between pediatric vs. adult patients.
- Administration workflow:
Individuals who described the administration process for WBD reported using the EHR primarily to verify medication information (e.g., dose, frequency). One individual reported personally double checking the math for weight-based medications.
Participants also spoke of challenges within the administration stage, including use of the wrong administration device, incorrect dose is drawn up, distractions/interruptions, delays in administration due to preparation requirements and lack of supplies, and device errors (e.g., pump-related challenges).
- EHR changes to mitigate WBD errors
Participants suggested many changes to mitigate these errors, including dynamic information checking during the ordering process, toggled displays, alterations to existing alert structures, and alterations to order sets. Participants also highlighted the need for human factors-based principles through the use of color to flag pediatrics vs. adult populations within the EHR, clear displays of trended weight data over time, and different fonts/colors to clarify the purpose of specific alerts.
Discussion: This qualitative analysis of prescribing, dispensing, and administering practices among healthcare professionals revealed critical insight to the dynamic practice of weight-based dosing for pediatric populations. We found substantial challenges in obtaining and synthesizing information to accurately prescribe, dispense, and administer weight-based medications in pediatric patients. Healthcare providers often had to manually perform tasks required checking, such as verifying patients’ weight and height, or decimal points. These tasks can impose high burden on providers and suggests a gap in the design of current EHR systems in safeguarding against such errors. Changing or adding safeguards will further enforce the ultimate goal of having system capabilities that protect patients from harm due to WBD errors.
Event Type
Oral Presentations
TimeMonday, March 2511:15am - 11:37am CDT
LocationSalon A-3
Patient Safety Research and Initiatives