Improving health IT patient safety

When it comes to health IT and patient safety, “we need more and better research to know what to work on first,” said Kathy Kenyon, JD, senior policy analyst at the Office of the National Coordinator for Health IT and moderator of a Jan. 10 webcast on the subject.

“Reporting of health IT-associated hazards and events is easier said than done,” Kenyon said. “A basic problem is helping clinical users and risk managers see the role of health IT in adverse events so they can report it.”

There is a low rate of voluntary reporting, she said, but one of the promises of health IT is that it can make reporting itself easier.

Incidents do not occur in isolation, said Cindy Wallace, senior risk management analyst for the ECRI Institute.

The top five health IT-related events, said Karen Zimmer, MD, medical director of patient safety, risk, and quality for the ECRI Institute: system interface, wrong input, software issue/system configuration, wrong record retrieved and software issue/functionality.

She said she advocates a continuous feedback approach to health IT system safety as well as leadership commitment to educating staff about health IT safety and advocating health IT safety as everyone’s responsibility. Organizations also need to promote open communication, allocate adequate resources and establish a blame-free environment for robust reporting of any health IT-related problems.

When there is an incident, an in-depth analysis must be conducted by a multidisciplinary team as well as those familiar with the particular hazard or incident, including health IT and other departments familiar with the technology, said Zimmer.

Following the investigation, staff should be provided with an analysis, said Wallace. “They need to know about error prevention strategies in place so they understand that reporting leads to improved patient care.” Attention to health IT safety is a continuous process in high reliability organizations.

EHR developers have shared responsibility with system users, said Zimmer, to support patient safety in their product design, development and deployment. They also should share best practices with customers for safe deployment, implementation, maintenance and use of their products. Vendors need to recognize the value of customers’ participation in discussions about patient safety and not contractually limit their customers from discussing patient safety issues in appropriate venues.

Health IT is changing the landscape of healthcare so it’s important to recognize the benefits and potential pitfalls, said Wallace. “Reporting health IT events and near misses will facilitate learning. Improvements will occur when multiple stakeholders are involved.”

One barrier to reporting of events is the likelihood of people to self-correct. “We need to make it easier to report,” said Wallace. “Lots of times people notice things, but because there isn’t an easy way to report, they tend to correct the issue and nobody hears about it.”

Organizations should identify someone to be responsible for coordinating event reporting, although it’s ultimately everyone’s responsibility. “Until everybody sees it as their responsibility and has it integrated into their everyday workflow, we’re going to have problems,” said Kenyon.

She added that health IT developers are “deeply committed to safety. I think that what we’re all struggling with is how to put together a risk management and patient safety structure that brings in everyone who needs to be involved to promote safety.” Good communication between the developers and users of EHRs, two-way communication, is important, she added. Developers need to share implementation and interface tips and users need to let developers know when products aren’t easy enough to use.

“We’re trying to encourage a dialogue that is part of a commitment to making certain that this very powerful technology is used to make healthcare safer. As long as people are blaming each other, it’s very hard to have the conversation.”