HARRISBURG: With limited data available on potential safety risks related to EHRs, the Pennsylvania Patient Safety Authority has published one of the largest compilations of safety issues related to EHRs in Pennsylvania healthcare facilities in its December Pennsylvania Patient Safety Advisory released today.
“When most people talk about the safety of health IT, they’re thinking of software bugs, hardware failures, or network problems. But our data show issues that are much more about the human-computer interface or the ways healthcare providers interact with the technology,” Bill Marella, MBA, program director for the Pennsylvania Patient Safety Authority, said. “While electronic health records will be the source of many improvements in the long run, in the short run it’s clear they are not a panacea for patient safety problems.”
Of the 3,099 EHR-related events analyzed by the Authority, 2,763 (89%) were reported as “event, no harm,” meaning an error occurred but there was no harm to the patient. Ten percent of the reports (320) were reported as “unsafe conditions,” which also did not result in a harmful event. Fifteen reports involved temporary harm to the patient due to the following: entering the wrong medication, ignoring a documented allergy, failure to enter lab tests and failure to document.
Marella said the Authority’s data is among the first large-scale examinations of these types of errors. Recently, the Institute of Medicine released a report, Health IT and Patient Safety: Building Safer Systems for Better Care, which notes a lack of hazard and risk reporting data on healthcare information technology as a hindering factor in building safer systems. Pennsylvania is the only state agency collecting this volume of data about EHRs.
“With the rapid adoption of electronic health records in the healthcare industry, there is growing concern that safety is not at the top of the agenda,” Marella added. “The Authority study gives not only Pennsylvania healthcare facilities, but all healthcare facilities implementing this technology, a glance at the potential problems they should anticipate and monitor after implementation.”
Since the Health Information Technology for Economic and Clinical Health Act (HITECH Act) legislation was signed into law in 2009, the healthcare industry is pushing to implement EHRs to collect financial incentives as part of the American Recovery and Reinvestment Act of 2009, the federal economic stimulus bill. Financial incentives will be offered until 2015.
“Among the problems this study identified,” Marella said, “are data entry errors not caught by the system, data entered into wrong fields, misreading or misinterpreting displayed information, and providers incorrectly accepting default values when entering orders.”
Marella added that problems related to wrong input (1,867) spanned a wide range of event types and outcomes: transposition or transcription errors in the entry of orders or administration information, entry of incorrect patient parameters (like weight or blood glucose) that trigger calculations of incorrect therapy, and even entry of the wrong physician name, resulting in reports being sent to the wrong recipient.
“Overall, almost four thousand problems were identified in the little more than three thousand reports analyzed. This analysis lays the groundwork for more focused studies of individual EHR safety issues.”
For more information about the EHR study, go to the December Pennsylvania Patient Safety Advisory article “The Role of the Electronic Health Record in Patient Safety Events,” on the Authority’s website at www.patientsafetyauthority.org.
The Authority’s 2012 December Advisory contains other clinical articles with toolkits for the healthcare provider to improve patient safety. Highlights include:
- Analysis of the Multiple Risks Involving the Use of IV FentaNYL: FentaNYL is a synthetic opioid that is a potent painkiller. It quickly reduces a patient’s pain with fewer side effects in comparison with morphine. Analysts reviewed medication errors and adverse drug reactions involving intravenous (IV) fentaNYL that were reported to the Authority. The most common medication error event types associated with IV fentaNYL were wrong-dose/overdosage events and wrong-drug events. Almost 68% of the reports mention breakdowns during the pump-programming process. High-alert medications were involved in almost 70% of wrong-drug events with fentaNYL. The article gives risk reduction strategies for reducing the risk of medication errors or adverse drug reactions when administering fentaNYL.
- Surgical Fires: Trends Associated with Prevention Efforts: Fires on the operating field are dangerous to patients and providers. The Authority analyzed 70 reports of fires submitted over seven years that occurred in the operating room on the surgical field. One-third of the reported events indicated harm to the patient. Risk to providers, rather than patients, was cited in six percent of the reports. Guidance on how to prevent fires in the operating field is detailed in this article. An educational toolkit is available with this article.
- Multifaceted Differences in Implementation of Practices for Prevention of Colorectal and Bariatric Surgical Site Infections: The Authority and the Pennsylvania National Surgical Quality Improvement Program (PA-NSQIP) initiated a collaborative project in December of 2010 to reduce surgical site infections (SSI) among the PA-NSQIP member hospitals and to transfer successful strategies and lessons learned to other PA hospitals. An SSI prevention assessment tool was developed to conduct on-site hospital interviews to assess the level of implementation of specific preventative practices at the pre-, intra-, and post-operative levels and to determine if the high-performing hospitals' lower SSI rate could be attributed to variation in implementation of practices. This article shows multifaceted differences in the implementation of practices and identifies specific interventions for facilities needing improvement to reduce SSIs related to bariatric and colorectal surgery. Two educational tools are available with this article.
- Potential Hazards of Clock Synchronization Errors: Information transfer from diagnostic or therapeutic devices, ancillary information systems such as laboratory and radiology departments, and electronic health record systems can be affected by disagreement between the clocks of medical devices, hospital networks, and watches or devices owned by clinicians and patients. From June 2004 through May 2012, three reports submitted by facilities determined that clock synchronization issues were a contributing factor to the event. However, Authority analysts noted that these events are not easily recognized and may be only a small portion of the actual number of clock synchronization events experienced in Pennsylvania hospitals. This article provides clock synchronization strategies to help reduce discrepancies.
- Wrong-Site Surgery Update: While wrong-site surgery reports of this quarter represent the fourth-lowest number of reports in a quarter since statewide reporting began, there were 11 reports of wrong-site surgery submitted to the Authority for the third quarter of 2012. Pennsylvania operating rooms went for the fourth time for more than a month without any reports of wrong-site surgery. Pennsylvania surgeons went 76 days without a wrong-site procedure. The rolling two-year average (49 per year) of wrong-site surgeries set a new low. The Authority knows the best practices to prevent wrong-site surgery. While many facilities have implemented these best practices, there are still wrong-site surgeries occurring in Pennsylvania. An updated toolkit and other resources are available on the Authority’s website for healthcare facilities to prevent wrong-site surgery.
For the complete 2012 December Pennsylvania Patient Safety Advisory, go to www.patientsafetyauthority.org.