Recently, my wife and I waited for our daughter to recover from a routine laparoscopic procedure. About twenty minutes after the surgeon came out to reassure us that all went well, we heard “code blue in the recovery room” over the intercom. A parent’s nightmare.
Last year, a publication entitled “Medical Error—the Third Leading Cause of Death in the US” by researchers at Johns Hopkins University argued that medical errors need to be taken as seriously as heart disease and cancer. The study focused on underreporting due to inadequate mechanisms for accurately reporting in-hospital patient deaths, such as missing ICD codes that would help classify medical error on death certificates. The study argued for greater transparency and increased industry awareness.
Coinciding with Patient Safety Awareness week, the ECRI Institute published its annual report of the Top Ten Patient Safety Concerns for Healthcare Organizations. “Information Management in EHRs” made the top of the list followed by “Unrecognized Patient Deterioration” and “Implementation and Use of Clinical Decision Support.” Patient Safety Organizations (PSOs) have access to adverse event reporting and offer health systems guidance by identifying opportunities to improve patient safety from an analysis of this data. The wide proliferation and adoption of Health Information Technology in the United States is playing an ever-larger role in significantly improving the quality of health care and reducing medical errors.
HIT Safety represents a prime opportunity to make a positive impact on reducing medical errors.
There are healthcare organizations that, while they have patient safety programs, do not actively engage and collaborate with IT departments to monitor, identify, analyze and mitigate risks to patient safety stemming from system-based errors. The ONC has signaled healthcare providers that HIT Safety is a priority and provides Safety Assurance Factors for EHR Resilience (SAFER) Guides, tools to help evaluate gaps in implementation of controls that can reduce medical errors where safety concerns are unique to EHR technology.
There are over 150 elements addressing data availability, integrity and confidentiality, complete and correct EHR use, safety surveillance, optimization and reporting. Organizational responsibilities are included to ensure decision-making activities and accountabilities are well-defined and reinforced.
Here are some of the risk categories addressed:
- System Configuration
- Contingency Planning
- System Interfaces
- CPOE with Clinical Decision Support
- Clinical Communication
- Patient Identification
Organizing teams to identify gaps in patient safety controls and implement projects to close the gaps, requires a commitment by leadership, physicians, staff, analysts and of project management resources. Though electronic health record systems do have varying degrees of baked-in safeguards, even the best systems require proper configuration and ongoing monitoring.
After nearly a week in an ICU and considerable trauma, our daughter is home and on the path to recovery. This close call was a brutal reminder of how vulnerable patients are in the hands of competent clinicians. We still do not know if technology played a role in her sentinel event, or if it could have played a preventive role. We do know that families also rely on measures taken to ensure the safety of the health information management technologies that also support their welfare.