Electronic Health Records and the Risk of Medication Errors

In this issue of Pediatrics, Merchant et al report on technology-related errors when high-risk medicines are prescribed for hospitalized children.1 Reviewing over 7000 high-risk medicine orders from 2 pediatric hospitals in Australia, they found errors in 20%. Of those, 24% were technology related, most commonly from duplicate drug therapy and incorrect drug doses. Roughly one-third of the errors were considered potentially serious. The authors do not comment on how many errors reached patients or resulted in harm. In many health care settings, there are intentional redundancies that include clinicians, nurses, and pharmacists to help prevent these kinds of errors. Nonetheless, these errors still occur and put patients at risk.The benefits of electronic health records (EHRs) with computerized provider order entry (CPOE) and clinical decision support (CDS) systems have2,3 not been fully realized. Although commercial EHR and drug database vendors have tools to support safe prescribing, the implementation of those tools is challenging. The specific needs of pediatric patients add layers of complexity that are not easily adopted.In the United States, the use of certified EHR technology is required to avoid downward payment adjustments for organizations receiving federal funds from Medicare.4 Although Medicaid incentives, which are more relevant to pediatric providers, expired at the end of 2021, nearly all eligible providers and hospitals have adopted and continue to use certified HER technology.5 The Assistant Secretary for Technology Policy (formerly the Office of the National Coordinator) Health Information Technology Certification Program’s list of certification criteria 170.315(a)(1) includes specification for CPOE of medications.6 However, the regulation for required elements only states, “Enable a user to record, change, and access medication orders.” Notably, there is no reference to critical aspects of pediatric prescribing, such as features to support weight-based dosing or to avoid exceeding a dose that would be given to an adult. Although seemingly fundamental, this can be challenging to achieve without guidance from clinicians and informaticians specializing in pediatrics and is beyond what is offered by EHR vendors. If not executed correctly, the EHR becomes a very expensive calculator with no guard rails. There are opportunities related to dose range checking embedded in EHRs, but neither criterion 170.315(a)4 on drug–drug and drug allergy interaction checks for CPOE, nor 170.315(a)(9) on CDS include checks for ensuring an appropriate dose is used.6The high rate of errors identified by Merchant et al raises important questions about the safety of CPOE systems and whether they offer sufficient CDS, especially considering some of the pediatric patients at the highest risk, those in the emergency department, intensive care unit, and hematology/oncology ward, were excluded from the study. There are many contributing factors to the errors, but they can be categorized in a framework related to errors because of humans, the computers, and the interaction between the two. Although computers have eliminated certain types of errors, like those because of illegible handwriting, they have facilitated others.7–9 The lack of knowledge likely contributes to some proportion of human errors, especially in academic centers where it is often trainee physicians entering many orders. However, even the most experienced clinicians make mistakes, particularly when interacting with a computer. These include the selection error reported by Merchant et al, in which a user inadvertently chose the wrong gentamicin dosing from a dropdown menu. Overreliance on technology also contributes to the problem, especially as prescribers are increasingly digital natives. Ordering clinicians may assume that if they enter an inappropriate dose in the EHR, the computer will stop them. Although this degree of decision support is worth striving for, the reality is that most health systems do not have sufficient informatics resources to build the extensive rules that would be needed to provide a level of indication-based decision support for pediatric patients.Fortunately, there can be both human and electronic checks in place downstream to protect patients from ordering errors. In keeping with the Conditions of Participation from the Centers for Medicare & Medicaid Services,10 EHRs include functionality for a pharmacist review before dispensing medications. This review may be tied to the same CDS alerts available to the prescriber as well as additional alerts specific to their role (eg, avoiding carbohydrate additives for patients on a ketogenic diet). Similarly, nurses must review medication orders before administration and can likewise have CDS and other safeguards, like barcode medication administration,11 in place to avert errors. These are in addition to prescribing safeguards, like the configuration of commonly ordered doses, embedded dosing calculators that compute off the patient’s weight or body surface area, and data validation tools to ensure orders are entered properly.In their analysis, Merchant et al focus on high-risk medications, which pose a greater risk to patients if not used as intended. Several of the medications in the study can be delivered to patients via intravenous pumps that exceed the traditional EHR ordering capability set. For example, insulin can be difficult to manage because of complex dosing regimens and the commercial availability of several concentrations mixed with customized dilutions to treat the smallest of patients. When delivered via specialized pump, ordering and tracking insulin delivery in an EHR that is effectively a third party to the specialized pump software is fraught with error. The same issue can happen for opioids and other pain medications delivered by multimodal pumps. Although not explicitly included in the study, total parenteral nutrition remains a challenge in pediatric settings. Although systems have advanced to allow weight-based dosing of components, this sometimes leads to a loss of awareness as to the specific amount of each component a patient is receiving, resulting in errors.Implementing EHRs effectively requires significant up-front commitment and ongoing investment from health systems. Beyond the cost, effective implementation requires clinicians from across disciplines and specialties to ensure the system supports existing clinical workflows or that effort is made to redesign the workflows and retrain clinicians. Early efforts at workforce development in clinical informatics estimated the need for 10 000 physicians and nurses by 2010 (at least one at each of the 6000 hospitals in the United States at the time).12,13 For physicians, the subspecialty of clinical informatics was recognized by the American Board of Medical Specialties in 2011,14 but to date, only 3054 have been board certified,15 and only a fraction of those have a primary specialty in pediatrics. The American Nurses Credentialing Center has a nursing-specific certification for informatics and has 3,438 total certified nurses as of 2024. The American Medical Informatics Association also has a certification that is open to all clinicians and began in 2022 but only has 146 diplomates as of 2025.The analysis by Merchant et al highlights the significant challenges implementing CPOE for pediatric patients, especially with respect to high-risk medicines. Despite the ability of electronic systems to integrate patient-specific data with extensive drug information, the current state of CPOE systems continues to rely heavily on clinician vigilance. This study emphasizes the critical need for ongoing workforce development in clinical informatics as well as interdisciplinary collaboration between physicians, nurses, pharmacists, and information technology professionals to better tailor systems to the needs of pediatric patients and providers at scale.