BEGIN:VCALENDAR VERSION:2.0 PRODID:Linklings LLC BEGIN:VTIMEZONE TZID:America/Chicago X-LIC-LOCATION:America/Chicago BEGIN:DAYLIGHT TZOFFSETFROM:-0600 TZOFFSETTO:-0500 TZNAME:CDT DTSTART:19700308T020000 RRULE:FREQ=YEARLY;BYMONTH=3;BYDAY=2SU END:DAYLIGHT BEGIN:STANDARD TZOFFSETFROM:-0500 TZOFFSETTO:-0600 TZNAME:CST DTSTART:19701101T020000 RRULE:FREQ=YEARLY;BYMONTH=11;BYDAY=1SU END:STANDARD END:VTIMEZONE BEGIN:VEVENT DTSTAMP:20240325T185833Z LOCATION:Salon A-3 DTSTART;TZID=America/Chicago:20240325T111500 DTEND;TZID=America/Chicago:20240325T113700 UID:HFESHCS_2024 International Symposium on Human Factors and Ergonomics i n Health Care_sess121_INDLEC245@linklings.com SUMMARY:A qualitative analysis of EHR prescribing workflows for weight-bas ed dosing in pediatric populations DESCRIPTION:Oral Presentations\n\nLaura Schubel, Garrett Foresman, and Ann a Jung (MedStar Health Research Institute); Sofia Teferi (MedStar Georgeto wn University Hospital); Naveen Muthu (Children's Hospital of Atlanta); Yu uki Unno (MedStar Health Research Institute); Bat-Zion Hose and Josh Biro (MedStar Health); and Sadaf Kazi (MedStar Health Research Institute)\n\nBa ckground: Pediatric clinicians provide care in an increasingly complex hea lthcare environment, which can increase opportunities for preventable harm .(Kirkendall et al., 2012; Walsh et al., 2014) Children are at greater ris k of harm compared to adults because minor errors in treatments such as me dications can have disproportionately harmful effects on children, making it important to institute weight-based dosing (WBD).(Commission, 2021; Kau shal et al., 2004) Accurate prescribing of weight-based medications requir es synthesizing a host of information: prescribers must know pertinent det ails about the patient, their medical condition, medication dosing, medica tion formulation, and how to apply sophisticated rounding strategies to av oid under- or over-dosing.(Russell et al., 2022) Although electronic presc ribing can help reduce some errors associated with WBD, a mismatch between EHR design and clinician workflows can also contribute to errors. The obj ective of our study was to investigate the workflow and workload involved in prescribing, dispensing, and administering weight-based medication in p ediatric 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 weigh t-based medications for pediatric patients.\n\nMethods: Semi-structured in terviews were conducted with 18 participants (n=7 physicians; n=2 nurses; n=6 pharmacists; n=6 health information technology [health IT] experts, wh erein three health IT experts had overlapping clinical roles and were cate gorized as both) with experience in using health IT for WBD and representi ng nine healthcare institutions and one research institute. Interview guid es were developed iteratively by a multidisciplinary team, including human factors engineers, physicians, and health researchers. Topics discussed i ncluded workflows and special circumstances for prescribing, dispensing, o r administering medications, tools to combat errors, and opportunities for improvement.\n\nConvenience sampling was used to recruit participants via word of mouth through clinician and research partners across a wide varie ty of clinical sites and geographic locations. Virtual interviews lasting approximately 60 minutes occurred in July and August 2023. A minimum of tw o 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 statement s before identifying themes. Coding discrepancies were resolved by discuss ion and consensus.\n\nResults: The tasks of prescribing, dispensing, and a dministering medications were described as specialty-specific, in which pr escribing was led by physicians (with pre-ordering tasks completed by nurs es or other hospital staff members), dispensing by pharmacists, and admini stering by nurses. Two participants reported that the ordering process is conducted primarily by resident attendees at their institutions. Exception s to role-specific practices occurred only in emergency situations in whic h there was not enough time to engage in the typical workflow. \n\n- Presc ribing workflow (pre-ordering and ordering):\nThe prescribing workflow com prised two main tasks: pre-ordering, and ordering. The pre-ordering workfl ow included gathering patient information including weight and chief compl aint, usually collected by nurses or other hospital staff. The ordering wo rkflow including selecting the medication and orders for administration, c omputing 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, especiall y when drafted by residents. In circumstances in which prescribers were re viewing patient information within the EHR such as weight or age, the majo rity relied on their clinical training to assess the accuracy of the data. \n\nParticipants mentioned substantial challenges within prescribing, incl uding challenges with ordering the intended route, frequency, or dose of m edication, 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 challenge s in the pre-ordering and ordering stages were attributable to device erro rs (e.g., faulty EHR systems, rounding errors, and challenges with imperia l 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 w eight and height information from a patient who is unwilling or otherwise unable to be measured in the moment, such as an emergency arrival). \n\n- Dispensing workflow:\nParticipants who described the medication dispensing process for WBD reported interacting with the EHR for all components of t he medication verification process. At the stage of medication preparation , the dispensing workflow comprised of closely reviewing information perti nent to weight-based including the appropriateness of the medication and d osing based on patient information (e.g., actual weight, dosing weight, et c.) and reviewing clinical information such as labs and patient history. C hallenges with dispensing included inability to capture weight in emergenc y situations, selecting the wrong dose, inability to concurrently see the medication data with the relevant patient information, and the EHR not cle arly differentiating between pediatric vs. adult patients.\n\n- Administra tion workflow:\nIndividuals who described the administration process for W BD 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.\nParticipants also spoke of challenges within the administration stage, including use of the wrong administratio n device, incorrect dose is drawn up, distractions/interruptions, delays i n administration due to preparation requirements and lack of supplies, and device errors (e.g., pump-related challenges). \n\n- EHR changes to mitig ate WBD errors\nParticipants suggested many changes to mitigate these erro rs, including dynamic information checking during the ordering process, to ggled displays, alterations to existing alert structures, and alterations to order sets. Participants also highlighted the need for human factors-ba sed principles through the use of color to flag pediatrics vs. adult popul ations within the EHR, clear displays of trended weight data over time, an d different fonts/colors to clarify the purpose of specific alerts.\n\nDis cussion: This qualitative analysis of prescribing, dispensing, and adminis tering 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, o r decimal points. These tasks can impose high burden on providers and sugg ests a gap in the design of current EHR systems in safeguarding against su ch errors. Changing or adding safeguards will further enforce the ultimate goal of having system capabilities that protect patients from harm due to WBD errors.\n\nTrack: Patient Safety Research and Initiatives\n\nSession Chair: Joseph Nuamah (Oklahoma State University) END:VEVENT END:VCALENDAR