Analyses shed light on health IT and patient safety

Analyses of adverse events reported to two patient safety organizations (PSOs) demonstrate the importance of standardized adverse event reporting while offering clues on how health IT impacts patient safety.

Kathy Kenyon, JD, senior policy analyst at the Office of the National Coordinator for Health IT (ONC), wrote in the agency’s Health IT Buzz blog about the analyses of hundreds of thousands of adverse events reported to PSOs University HealthSystem Consortium (UHC) and the ECRI Institute.

ONC’s final report offered several findings. In the ECRI database, health IT involvement in an adverse event report was indicated only 4 percent of the time. This means that the narrative text must be included in such reports to determine the root cause of the problem.

In the UHC database, healthcare organizations indicated health IT involvement approximately half of the time. Upon further analysis, the researchers found that incidents involving health IT were less likely to result in harm when compared to those events that were not health IT-related, Kenyon wrote.

In other findings from the UHC data, as reported in the blog:

• The most frequent 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).
• Medication-related events were the most common health IT-related event type, accounting for about 33 percent of these events.
• 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.
• About 60 percent of the events involving health IT were categorized as an incident, 14 percent as near miss event and 26 percent as an unsafe condition.
• Clinical documentation systems, computerized provider order entry and laboratory information systems are among the types of IT most commonly involved in adverse events.

“Healthcare organizations and health IT developers, working with patient safety organizations, can use evidence like this to focus their efforts to use health IT to make care safer and to continuously improve the safety of health IT,” wrote Kenyon.