While information technology has vast potential to improve patient outcomes, the ECRI Institute has ranked a health IT-related issue as the top 2016 patient safety concern facing healthcare organizations.
Heading ECRI’s list of this year’s top 10 patient safety worries is “health IT configurations and organizational workflow that do not support each other.” As ECRI’s report points out, when HIT configuration and workflow clash, communication suffers and can lead to delays in care or even medical errors.
That wasn’t the only patient safety concern with a health IT connection, says Bill Marella, executive director of patient safety reporting systems at ECRI.
“There are a number of topics on the Top 10 list this year that relate to IT, which is a function of the massive investment we’ve made in electronic health records and other systems,” Marella says. “The task for us is to optimize them and make sure that they support clinicians rather than detract from their workflow and create more work for them to do.”
ECRI notes that providers have seen a range of unintended consequences from the implementation of electronic health records that introduce new areas of risk, including patient identification errors (ranked second) and medication errors (ranked seventh).
“I think overall we’re actually safer with EHRs than we were on the paper system, but there are some growing pains associated with having put these systems in so quickly,” adds Marella. “The EHR is now the chief vehicle for clinicians communicating with one another. If the information in that system is not valid or reliable, that seriously undermines the quality of care.”
ECRI recommends that organizations involve frontline staff in planning and configuring health IT and testing its integration with workflow. Other strategies include watching for workarounds and incorporating ways to indicate the contribution of HIT issues in event-reporting systems.
Despite the widespread adoption of EHRs, correctly identifying patients and accurately matching their records continues to be a difficult problem, according to ECRI analysts who discovered that patient identification issues were not only frequent but serious. Marella says one of the major sources of identification errors occurs when busy doctors and nurses have multiple patient records open simultaneously and they accidentally input an order into the wrong chart without realizing it.
He argues that having a staff policy in place that limits the number of electronic records that can be open at the same time is critical, as well as incorporating patient photographs into the EHR to ensure visual identification.
“Organizations can improve staff members’ use of two identifiers, such as by investigating and addressing reasons staff do not follow policies, and by actively involving patients,” states the report. “And although they are not a panacea, potential adjunct strategies include bar coding and alerts that flag mismatches between orders and the problem list.”
Nonetheless, as Marella acknowledges, alerts are often ignored by clinicians who suffer from what he calls “alert fatigue” in which staff who are constantly bombarded with urgent notifications simply tune them out, significantly increasing the likelihood of making medical errors.
When it comes to medication errors, ECRI’s report focuses on those errors related to the faulty input of pounds and kilograms in EHR data fields. For instance, Robert Wachter, MD, professor and associate chair of the Department of Medicine at the University of California, San Francisco, documented a case at his hospital in which a 39-fold overdose of a routine antibiotic was given to a pediatric patient as result of a simple screen error where the doctor didn’t realize that she was prescribing in milligrams of drug per kilogram of weight. And, although electronic alerts warned the doctor and later the pharmacist of the error, they ignored them.
“There are still a lot of hospitals that are reporting these kinds of medication errors to us, despite the fact that they have EHRs,” Marella says. “The problem is when you enter a number that’s really a weight in kilograms but you put it in the pounds field. This is an instance of the clinician giving the system bad information.”
According to ECRI, one of the most effective strategies to reduce the risk of such errors is to get rid of scales that measure in pounds. In addition, the report advises that clinical decision support—such as functions that compare entered weight with expected weight—also may help avoid errors.
An aspect of patient safety involving EHRs that was not addressed in this ECRI report involves data errors that result from physicians who use copy and paste functions to input information. Only about one-quarter of hospitals have policies regarding the use of the copy-paste feature in EHR technology, according to the Office of the Inspector General of the Department of Health and Human Services.
In 2013, ECRI convened the Partnership for Health IT Patient Safety, a multi-stakeholder collaborative focused on improving the safety of HIT, including examining the unsafe aspects of copy and paste in EHRs. The Partnership’s first workgroup just released safe practices for using copy and paste in order to help ensure high quality clinical documentation and the integrity of health information, which is available here.
“We didn’t think it was realistic or desirable necessarily to completely outlaw copy and paste. But, you do have to have systems in place to make clinicians accountable for the veracity of the information that they enter,” Marella says.
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