Pediatric Informatics: Computer Applications in Child Health (Health ...

8 Complexity in Healthcare Information Technology Systems 95
hospitals to (perhaps in part prematurely) implement electronic “solutions” without
fully understanding how to specify, purchase, and implement, test and maintain
Health IT systems that can manage the complex operational interdependencies that
have profound impact on safe patient care. 58–64
The human culture of inpatient Pediatric environments has evolved to a safer
level: Today physicians, pharmacists, and allied health personnel work synergistically
to deliver care. This coordinated “symphony” delivers complex, time-sensitive care
to many pediatric patients simultaneously and is often called “workflow.” In the
inherently dynamic period of childhood, these providers work collaboratively to
identify risk factors and prevent harm. In many cases, the introduction of new
technology interrupts communication, redirects efforts, and places unanticipated
stress on these delicate human systems, sometimes with untoward consequences.
Change magnifies inefficiencies, demolishes existing work-arounds, and disrupts
the delicate workflow balance that stabilizes a complex Pediatric ward.
Scenario B addresses the interrelationship of human factors and technology
in a Pediatric ward, and describes the occult workflow problems that technol-
ogy exposed. Children create distinctive challenges for medication ordering.
Pediatric patients have threefold the risk of adults for suffering harm from a medication
error. Pediatricians must calculate medication doses based on weight, age,
gestational age, and indication, increasing the risk of cognitive and mathematical
errors (e.g. the tenfold overdose error). 64 Pediatric pharmacists often work with
adult formulations, and must manually compound suspensions and intravenous
dilutions for use in pediatric patients. Children experience rapidly changing
weights and sequentially changing laboratory normative values, which increases
risk for incorrect dosing. The immature renal and hepatic systems in children and
neonates inconsistently clear drugs, and limited physiologic reserve makes infants
more likely to be harmed by even modest medication errors. 64–66 Computer systems
with inappropriate normal values and adult-based decision support modules
increase error risk. Efficient communication between providers helps mitigate this
risk, but technology often constitutes a barrier to human interaction.
8.3.2 Scenario B: Situation Analysis
Two published studies from major children’s hospitals with very different results on
PICU mortality 8, 9 raise a key question: How can two Pediatric CPOE implementations,
using the same commercial system, produce completely different patient
mortality outcome results?
8.3.2.1 Review: Comparison of the Case Details
The Pittsburg Children’s Hospital 8 is a nationally recognized 235 bed tertiary
pediatric care facility admitting about 12,000 pediatric patients per year; 25% of
the admissions are directly to the hospital’s Pediatric ICU (PICU). Pittsburg
64, 65