The Office of the National Coordinator for Health Information Technology is offering new guidance on identifying unsafe conditions with electronic health records.
When front line clinicians confront a clinical mishap or unsafe condition in EHR-enabled health care settings (such as a medication error or a missed diagnosis) they may not connect the clinical event with how EHR use could have helped prevent it, how misuse or failure to use EHR functionality as intended contributed to the problem, or how weaknesses in EHR configuration, interfaces, or usability contributed, according to a new ONC blog posting.
Consequently, ONC has two new guidance documents, both authored by ECRI Institute under a contract with the agency. A report, How to Identify and Address Unsafe Conditions Associated with Health IT, focuses on improving the reporting of unsafe conditions associated with an HIT product. Another document with 43 slides accompanies the report.
The report encourages use of two standardized reporting tools from the Agency for Healthcare Research and Quality--AHRQ Common Formats version 1.2 and AHRQ Hazard Manager--to enable aggregation and comparison of HIT-related events over time.
This guide also addresses the need for follow-up on reports, according to the ONC blog. Busy people in healthcare (as in other fields) need feedback or they tend not to report. The work of providing that feedback begins with healthcare organizations. However, when it comes to understanding health ITs role in safety events, healthcare organizations may need help. This guide describes how patient safety organizations and EHR technology developers can help by, for example, bringing analytical sophistication that helps tease out the complex sociotechnical factors involved in health IT-associated events. Patient safety organizations can also provide a legally protected space for reporting and follow-up, including the involvement of EHR developers.
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