A red‐flag‐based approach to risk management of EHR‐related safety concerns
01 Jan 2013-Journal of healthcare risk management : the journal of the American Society for Healthcare Risk Management (J Healthc Risk Manag)-Vol. 33, Iss: 2, pp 21-26
TL;DR: In this article, the authors present a "red flag"-based approach that can be used by risk managers to identify potential EHR-related safety concerns in their institutions, such as incorrect patient identification, extended EHR unavailability (either planned or unplanned), failure to heed a computer-generated warning or alert, system-to-system interface errors, failure to identify, find, or use the most recent patient data; misunderstandings about time; incorrect item selected from a list of items; and open or incomplete orders.
Abstract: Although electronic health records (EHRs) have a significant potential to improve patient safety, EHR-related safety concerns have begun to emerge. Based on 369 responses to a survey sent to the memberships of the American Society for Healthcare Risk Management and the American Health Lawyers Association and supplemented by our previous work in EHR-related patient safety, we identified the following common EHR-related safety concerns: (1) incorrect patient identification; (2) extended EHR unavailability (either planned or unplanned); (3) failure to heed a computer-generated warning or alert; (4) system-to-system interface errors; (5) failure to identify, find, or use the most recent patient data; (6) misunderstandings about time; (7) incorrect item selected from a list of items; and (8) open or incomplete orders. In this article, we present a "red-flag"-based approach that can be used by risk managers to identify potential EHR safety concerns in their institutions. An organization that routinely conducts EHR-related surveillance activities, such as the ones proposed here, can significantly reduce risks associated with EHR implementation and use.
Citations
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TL;DR: A new framework is proposed, the Health IT Safety (HITS) measurement framework, to provide a conceptual foundation for health IT-related patient safety measurement, monitoring, and improvement and to integrate both retrospective and prospective measurement of HIT safety with an organization's existing clinical risk management and safety programs.
Abstract: Health information technology (health IT) has potential to improve patient safety but its implementation and use has led to unintended consequences and new safety concerns. A key challenge to improving safety in health IT-enabled healthcare systems is to develop valid, feasible strategies to measure safety concerns at the intersection of health IT and patient safety. In response to the fundamental conceptual and methodological gaps related to both defining and measuring health IT-related patient safety, we propose a new framework, the Health IT Safety (HITS) measurement framework, to provide a conceptual foundation for health IT-related patient safety measurement, monitoring, and improvement. The HITS framework follows both Continuous Quality Improvement (CQI) and sociotechnical approaches and calls for new measures and measurement activities to address safety concerns in three related domains: 1) concerns that are unique and specific to technology (e.g., to address unsafe health IT related to unavailable or malfunctioning hardware or software); 2) concerns created by the failure to use health IT appropriately or by misuse of health IT (e.g. to reduce nuisance alerts in the electronic health record (EHR)), and 3) the use of health IT to monitor risks, health care processes and outcomes and identify potential safety concerns before they can harm patients (e.g. use EHR-based algorithms to identify patients at risk for medication errors or care delays). The framework proposes to integrate both retrospective and prospective measurement of HIT safety with an organization's existing clinical risk management and safety programs. It aims to facilitate organizational learning, comprehensive 360 degree assessment of HIT safety that includes vendor involvement, refinement of measurement tools and strategies, and shared responsibility to identify problems and implement solutions. A long term framework goal is to enable rigorous measurement that helps achieve the safety benefits of health IT in real-world clinical settings.
118 citations
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TL;DR: This phenomenological study explored nurses' perceptions regarding electronic health records and bar code medication administration four months post implementation on a medical-surgical unit in an academic medical center and discovered that effective health IT must be congruent with nursing expectations.
44 citations
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TL;DR: Important areas of risk during EHR downtime periods were patient identification and communication of clinical information; these should be a focus of downtime procedure planning to reduce safety hazards.
41 citations
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TL;DR: Based on a large number of Finnish EHR users in hospitals, this study indicates that HIT safety hazards should be taken very seriously, particularly in operating rooms, procedure units, emergency departments, and intensive care units/critical care units.
Abstract: Background: The rapid expansion in the use of electronic health records (EHR) has increased the number of medical errors originating in health information systems (HIS). The sociotechnical approach helps in understanding risks in the development, implementation, and use of EHR and health information technology (HIT) while accounting for complex interactions of technology within the health care system. Objective: This study addresses two important questions: (1) ?which of the common EHR error types are associated with perceived high- and extreme-risk severity ratings among EHR users??, and (2) ?which variables are associated with high- and extreme-risk severity ratings?? Methods: This study was a quantitative, non-experimental, descriptive study of EHR users. We conducted a cross-sectional web-based questionnaire study at the largest hospital district in Finland. Statistical tests included the reliability of the summative scales tested with Cronbach?s alpha. Logistic regression served to assess the association of the independent variables to each of the eight risk factors examined. Results: A total of 2864 eligible respondents provided the final data. Almost half of the respondents reported a high level of risk related to the error type ?extended EHR unavailability?. The lowest overall risk level was associated with ?selecting incorrectly from a list of items?. In multivariate analyses, profession and clinical unit proved to be the strongest predictors for high perceived risk. Physicians perceived risk levels to be the highest (P<.001 in six of eight error types), while emergency departments, operating rooms, and procedure units were associated with higher perceived risk levels (P<.001 in four of eight error types). Previous participation in eLearning courses on EHR-use was associated with lower risk for some of the risk factors. Conclusions: Based on a large number of Finnish EHR users in hospitals, this study indicates that HIT safety hazards should be taken very seriously, particularly in operating rooms, procedure units, emergency departments, and intensive care units/critical care units. Health care organizations should use proactive and systematic assessments of EHR risks before harmful events occur. An EHR training program should be compulsory for all EHR users in order to address EHR safety concerns resulting from the failure to use HIT appropriately. [JMIR Med Inform 2016;4(2):e13]
38 citations
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TL;DR: Given the rapid adoption of EHRs by many organizations that are still early in their experiences with EHR safety, it is important to understand practices for maintaining resilience used by organizations with a track record of success in EHR use.
Abstract: Electronic health record systems (EHRs) can improve safety and reliability of health care, but they can also introduce new vulnerabilities by failing to accommodate changes within a dynamic EHR-enabled health care system. Continuous assessment and improvement is thus essential for achieving resilience in EHR-enabled health care systems. Given the rapid adoption of EHRs by many organizations that are still early in their experiences with EHR safety, it is important to understand practices for maintaining resilience used by organizations with a track record of success in EHR use. We conducted interviews about safety practices with 56 key informants (including information technology managers, chief medical information officers, physicians, and patient safety officers) at two large health care systems recognized as leaders in EHR use. We identified 156 references to resilience-related practices from 41 informants. Framework analysis generated five categories of resilient practices: (a) sensitivity to dynamics and interdependencies affecting risks, (b) basic monitoring and responding practices, (c) management of practices and resources for monitoring and responding, (d) sensitivity to risks beyond the horizon, and (e) reflecting on risks with the safety and quality control process itself. The categories reflect three functions that facilitate resilience: reflection, transcending boundaries, and involving sharp-end practitioners in safety management.
21 citations
References
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TL;DR: A typology of clinicians' workarounds when using barcoded medication administration (BCMA) systems is developed, finding nurses overrode BCMA alerts for 4.2% of patients charted and for 10.3% of medications charted.
657 citations
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TL;DR: Reminders about orders for apparently redundant laboratory tests were effective when delivered, however, the overall effect was limited because many tests were performed without corresponding computer orders, and many orders were not screened for redundancy.
297 citations
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TL;DR: The authors characterized errors in several converging aspects of the drug ordering process: confusing on-screen laboratory results review, system usability difficulties, user training problems, and suboptimal clinical system safeguards that all contributed to a serious dosing error.
198 citations
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TL;DR: Hospitals and clinics are adapting to new technologies and implementing electronic health records, but the efforts need to be aligned explicitly with goals for patient safety.
Abstract: Hospitals and clinics are adapting to new technologies and implementing electronic health records, but the efforts need to be aligned explicitly with goals for patient safety. EHRs bring the risks of both technical failures and inappropriate use, but they can also help to monitor and improve patient safety.
189 citations
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TL;DR: Beside the range of functionalities provided by a CPOE system, their subtle design is important to increase physicians' adoption and to reduce medication errors, which requires continuous evaluations to investigate whether interfaces of CPOEs follow normal flow of actions in the ordering process.
Abstract: Objectives: To examine the impact of design aspects of computerized physician order entry (CPOE) systems for medication ordering on usability, physicians’ workflow and on medication orders. Methods: We systematically searched PubMed, EMBASE and Ovid MEDLINE for articles published from 1986 to 2007. We also evaluated reference lists of reviews and relevant articles captured by our search strategy, and the web-based inventory of evaluation studies in medical informatics 1982–2005. Data about design aspects were extracted from the relevant articles. Identified design aspects were categorized in groups derived from principles for computer screen and dialogue design and user guidance from the International Standard Organization, and if CPOE-specific, from the collected data. Results: A total of 19 papers met our inclusion criteria. Sixteen studies used qualitative evaluation methods and the rest both qualitative and quantitative. In total 42 CPOE design aspects were identified and categorized in seven groups: 1) documentation and data entry components, 2) alerting, 3) visual clues and icons, 4) drop-down lists and menus, 5) safeguards, 6) screen displays, and 7) auxiliary functions. Conclusions: Beside the range of functionalities provided by a CPOE system, their subtle design is important to increase physicians’ adoption and to reduce medication errors. This requires continuous evaluations to investigate whether interfaces of CPOE systems follow normal flow of actions in the ordering process and if they are cognitively easy to understand and use for physicians. This paper provides general recommendations for CPOE (re)design based on the characteristics of CPOE design aspects found.
176 citations
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