Challenges Remain for Using Common Formats to Understand Adverse Events

Though patient safety organizations can use the Agency for Healthcare Research and Quality’s Common Formats in working with the provider community to understand, monitor and reduce safety events, there are particular challenges in implementing them with regard to health IT-related adverse events.

That is the finding of ONC-funded analyses of adverse events reported to two PSOs—UHC and the ECRI Institute—which analyzed the structured data from the AHRQ Common Formats, including standard questions and narrative text fields about all types of adverse events (not just questions on health IT) in their reporting systems.

In the ECRI reporting system, only 4 percent of reported events had a response to the questions regarding health IT involvement, which limited analyses of HIT-related adverse events. However, in the UHC reporting system, the Common Formats Yes/No question on health IT involvement was answered approximately half the time, providing a large enough database for further analysis.

Overall, the study concludes that incidents involving health IT were less likely to result in harm when compared to those events that were not HIT-related. Yet, more than half of the health IT-related events were categorized in the Common Formats “other” report category making it difficult to determine the clinical problem involved in these events from these data.

In addition, when comparing answers to the Common Formats question on whether an event was health IT-related to a more in-depth review of the event, UHC revealed that an estimated 31 percent of the events coded as health IT-related were not actually health IT-related, and over 25 percent of the events that actually were health IT-related were not coded as such.

Among the other findings:

*The most common contributing factors to health IT-related events were communication among staff and team members (40-42 percent), staff inattention (33-34 percent), accuracy of the data (21-23 percent), and availability of data (10-12 percent). These factors were more frequently identified in health IT-related events than in events that were not health IT-related.

*Medication-related events were the most common health IT-related event type, accounting for about one-third of these events.

*About 60 percent of the events involving health IT were categorized as an incident (i.e., they reached a patient although they may not have resulted in harm to the patient), 14 percent as near miss event, and 26 percent as an unsafe condition.

*The UHC data showed that clinical documentation systems, computerized provider order entry (CPOE), and laboratory information systems are among the types of IT most commonly involved in adverse events. Health IT-related issues were common in the interfaces between different software components that make up health IT systems.

“While the analyses of the UHC and ECRI data suggest that work must be done to make the Common Formats a more useful tool for aggregating and understanding adverse events in healthcare, they are necessary for learning across healthcare organizations about the complex factors, including the role of health IT, that contribute to patient safety,” concludes the report.