“Because EHR-related safety concerns have complex socio-technical origins, institutions with longstanding, as well as recent EHR implementations, should build a robust infrastructure to monitor and learn from them,” concluded the report published Friday in the Journal of the American Medical Informatics Association.
Researchers evaluated 100 closed safety investigations reported between August 2009 and May 2013 to the Informatics Patient Safety Office of the Veterans Health Administration. Among the findings, 74 events resulted from unsafe technology, such as system failures, computer glitches, false alarms or “hidden dependencies,” a term for what happens when a change in one part of a system inadvertently leads to key changes in another part. Another 25 events involved unsafe use of technology such as an input error or a misinterpretation of a display.
The report highlighted case studies detailing how EHR complexities span various dimensions including software and interface, or workflow and communications. In one example, a pharmacist made a data entry error, inputting a higher dose of a diuretic than what was prescribed. A warning appeared, but that particular warning was known to have a high false-positive rate. As a result, the pharmacist had poor confidence in the warning's reliability, and the warning was over-ridden. The incorrect dose was sent to a nurse, who was never aware of the discrepancy. The patient was then administered the higher dose.
“It's not just the technological complexity, it's also the social aspect around technology,” explained study co-author Dr. Hardeep Singh, a safety researcher at the Center for Innovations in Quality, Effectiveness and Safety at the Michael E. DeBakey Veterans Affairs Medical Center and associate professor in the department of medicine at the Baylor College of Medicine. “We're just now beginning to get an understanding of this,” he said.
The Veterans Affairs Department has maintained a voluntary reporting system to investigate EHR-associated adverse events since 1999, which the study authors said provided the infrastructure to collect data. Even after the system had been in place for years, these types of errors were noted, which Singh said is a reminder of why it is important to be proactive about monitoring EHR-related issues.
“It's a continuous learning environment,” said Singh, who is concerned that many places now aiming to meet meaningful-use or ICD-10 guidelines are not rigorously evaluating patient-safety events related to healthcare information technology.
“People are mostly working to meet the federal requirements, and not paying as much attention to the patient safety issues,” he said. Singh recommended hospitals look at the SAFER Guides, a list of EHR implementation and monitoring resources issued in February by the Office of the National Coordinator for Health Information Technology.
Other patient safety experts also have noted the complexities of introducing new healthcare IT systems into already complicated healthcare environments.
At a session during the Modern Healthcare Patient Safety & Quality virtual conference June 18, Debora Simmons, senior vice president and chief quality officer of St. Luke's Episcopal Health System in Houston, noted counterproductive features such as drop-down menus that are too narrow to allow users to see all of the information they need, or a medication list so lengthy, a clinician cannot find a drug he is seeking.
Such negative features may seem trivial, but “it's a huge deal,” Simmons said. “It's incredibly important to make it very clear, so clinicians get the information without any ambiguous extras as they go through their work day.”
As hospitals move to integrate electronic records systems, they should keep in mind the potential complications associated with connectivity, she said. Though it sounds good in theory— connecting the order entry to the patient's medication record which is connected to the pharmacy system, which is connected to the billing system—there are many potential downsides.
“If you make a change at one part of the system, it's like dominoes falling down. It affects everything,” Simmons said. “And the more complexities built into the system, the more difficult it is to trace.”
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