Studied by 6 people
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1971
year when the first EHR with CPOE was introduced
American Recovery and Reinvestment Act (ARRA)
authorized the HITECH Act, which allocated $17 billion to stimulate the adoption of quality health IT systems or EHRs that demonstrate meaningful use
Dr. Sengstack
the Chief Nursing Informatics Officer in the Center for Clinical Excellence and Innovation for the Bon Secours Health System
President of the American Nursing Informatics Association
To Err is Human
published in 1999 by the Institute of Medicine (IOM)
Has been a driving force for improvements in patient safety across the nation
Demonstrated evidence that
Journal of the American Medical Association
a popular study published by Koppel et al in 2005
Reported that CPOE systems actually facilitate medication errors
Using quantitative and qualitative methods, 22 types of medication error risks associated with the use of CPOE were identified
Study by Walsh et al.
created a retrospective study which attempted to determine the frequency and types of pediatric errors attributable to design features in a CPOE system
The rate of identified computer-related errors was 10 errors per 1000 patient days
The rate of “serious” computer-related errors was 3.6 errors per 1000 patient days
Study by Han et al. (2005)
a study that observed an unexpected increase in mortality in a pediatric ICU that coincided with the implementation of their CPOE system
Qualitative Study by Campbell, Sittig, Ash, Guappone, and Dyskra
A study conducted which attempted to identify the types of unintended consequences seen with the implementation of EHR systems with CPOE
This study involved an expert panel using an iterative process that took a list of adverse consequences of CPOE, and sorted them into categories
One category labeled is: Generation of New Kinds of Errors
Generation of New Kinds of Errors
a category created in the published study by Campbell, Sittig, Ash, Guappone, Dykstra
indicated that new kinds of errors appear when CPOE is implemented
Examples of items in this category include:
Juxtaposition errors when users select an item next
to the intended choice
A wrong patient being selected;
Desensitization to alerts (alert overload);
Confusing order option presentations;
System design issues with poor data organization
and display
Office of the National Coordinator (ONC) for Health Information Technology
Requested that the IOM form a team of experts to assess the current state of EHRs and their ability to improve patient safety
Health IT and Patient Safety: Building Safer Systems for Better Care
published on November 2011 by IOM
235-page document that provides a comprehensive description of the state of EHRs and their ability to improve px safety
Threats to patient safety as outlined by the IOM
Poor user interface design
poor workflow support
complex data interface
poor user interface design
refers to the process of creating the look and feel of the product
poor workflow support
refers to the use of systems to streamline HC processes
improves efficiency and outcomes
to avoid med errors, delays, staff burnout
contributing factors identified by IOM leading to unsafe conditions in CPOE or EHR use
lack of system interoperability
the need for clinicians to review data from multiple systems
HHS
health and human services
July 2013
year when ONC published their response to the IOM report in the form of the Health Information Technology Patient Safety and Action & Surveillance Plan
ONC for HIT-Safety Plan
iterated the challenge of discerning if health IT is the true cause of medical errors
addresses the need to focus on learning and assessing the current status prior to developing the solution
ONC’s Action and Surveillance Plan
use of Health IT to make care safer
continuously improve the safety of Health IT
3 Key areas where the ONC HIT-Safety Plan revolves around
recognizing the fact that there is much to learn in this area
learning
improving
leading
PSOs
patient safety organizations
establishment of processes and mechanisms that facilitates reporting
recommended along with the strengthening the use of state and national Patient Safety Organizations
to help collect and report on these issues
needs that are recognized for Health IT errors
the need for standard terminologies to report health IT-related errors
the need to process and report them centrally
a method to aggregate and analyze data
AHQR
Agency for Healthcare Research and Quality
Agency for Healthcare Research and Quality
develops and maintains a set of common formats that include a set of common definitions
allows organizations to collect and submit standardized information regarding health IT-related patient safety events and hazards
improvement efforts by the ONC
The goal is to develop resources and evidence-based corrective actions to improve health IT safety and px safety
10 patient safety domains
adverse drug events
catheter-associated UTI
central-line associated bloodstream infections
readmissions
ventilator-associated pneumonia
pressure ulcers
surgical line infections
obstetrical adverse events
venous thromboembolism
injuries from falls and immobility
catheter-associated UTI
Associated with urinary bag to cause infections
central line-associated bloodstream infections
usually occurs when bacteria enters the central line to the bloodstream
usually related to dialysis
ventilator-associated pneumonia
pneumonia that develops 48 hrs after ventilator has been given
pressure ulcers
usually associated with bedridden and elderly clients
Transdermal therapeutic system q2h
venous thromboembolism
associated with blood clot formations
Collaborated agencies with ONC
Food and Drug Administration
Federal communications commission
common formats
an area of focus that has been developed for reporting patient safety events
in using this for reporting, it is hoped that standardized data will provide valuable analysis and trending that can lead to more focused efforts and significant improvements in px safety
patient safety organizations
emerged as part of the Patient Safety and Quality Improvement Act of 2005
has 77 organizations in 29 states listed by the AHQR
PSOs
Through these organisations that will help in the collection of data on patient safety and submit non-identified data to AHRQ's Network of Patient Safety Databases
PSO Privacy Protection Center's Website
Descriptions and contributing factors for health IT safety issues are listed and can be used when reporting incidents, near misses, and unsafe conditions
houses the Common Formats for standardized reporting of Health IT related errors
Health IT hazard manager
Tool completed by AHRQ in 2011
Gives hc providers a method of capturing and managing hazard data in software that includes near miss errors and actual errors
Vendors will receive the safety reports relevant ONLY to their products
Health IT hazard manager
Funded with a $750 000 grant led by Abt Associates with the ECRI Institute and Geisinger Health System's Patient Safety Institute
Health IT hazard manager
Does NOT allow hc providers to share data collected with the tool among themselves, but only see their own reports
healthcare’s key stakeholders
EHR vendors
hospitals
ambulatory practices
home health agencies
long term care facilities
federal government
Other Studies
another study that highlighted how na EHR perpetuated a deadly IV order of potassium that was left unchecked
1) Health IT and Patient Safety Recommendation
The secretary if HHS should publish an action and surveillance within 12 months that includes a schedule for working with the private sector to assess the impact of health IT
2) Health IT and Patient Safety Recommendation
The secretary of HHS should ensure insofar as possible that health IT endors support the free exchange of information about health IT experiences and issues and not prohibit sharing of such inform, including details relating to patient safety
3) Health IT and Patient Safety Recommendation
The ONC should work with the private and public sectors to make comparative user experiences across vendors publicly available
Organizations which ONC intends to align with as part of the HITECH Act
National Quality Strategy (NQS) and;
the Center for Medicare and Medicaid Services Partnership for Patients
the Center for Medicare and Medicaid Services (CMS) Partnership for Patients
Organization that set the 10 Patient Safety Domains that supports improvement efforts for Health IT
FDA
Has been concerned with patient safety since its inception
Receives medical device reports (MDRs) of suspected device-associated deaths
Manufacturer and User Facility Device Experience (MAUDE)
a database that contains MDRs into its system for centralized housing, analysis, and reporting
a limitation of this database is its age
Its capabilities to conduct real-time reporting and analysis are limited
This affects its ability to generate and evaluate evidence
PRIMO
Pharmacovigilance Report Intake and Output Management
PRIMO Software System
A new database that will take its place according to a press release statement
Food and Drug Administration Safety and Innovation Act (FDASIA)
Enacted by the Congress on July 2012
Its intent is for the framework to promote innovation, protect patient safety, and avoid regulatory duplication
Institute for Safe Medication Practices
Devoted entirely to medication error prevention and safe medication use
Their mission is to lead efforts to improve the medication use process
Institute for Safe Medication Practices
They have published multiple guidelines and tips for the designers of EHRs as they configure medication orders and order sets.
Created the Guidelines for Standard Order Sets
Institute for Safe Medication Practices
certified as a Patient Safety Organization (PSO) by AHRQ
receives error reports from healthcare professionals
Guidelines for Standard Order Sets
made by the ISMP
provides a 5-page checklist that allows organizations to evaluate the safety of their CPOE systems
Medication Errors Reporting Program
Robust voluntary error-reporting program of the ISMP
A system where practitioners can report any errors related to medication use
ECRI
A non profit organization, focused on scientific research to discover the effectiveness of medical procedures, devices, drugs, and process, to improve patient care
Evaluation of health IT-related events
The ECRI conducted a evaluation on December 2012
It was about the health-IT related events and unsafe conditions with the goal of improving the understanding of technology’s impact on healthcare delivery
Frequently Identified Health IT-related problems
system interface Issues
Wrong input
Wrong record retrieved
Software issue/ system configuration
Software issue/ functionality
Anticipating Unintended Consequences of Health Information Technology and Health Information Exchange: How to Identify and Address Unsafe Conditions Associated with Health IT
A report that followed after the 5 Frequently Identified Health IT related problems
Included examples of commonly encountered health IT-related incidents
examples of commonly encountered health IT-related incidents
the user ignored or override an alert
Test results were sent to the wrong provider causing delay
Text entries were not shared due to poor UI
Leapfrog Group
It is CPOE opinion leader, that represents a coalition of healthcare purchasers that has been a driving force in the improvement of healthcare quality
Leapfrog Group
They are strong advocates for the use of CPOE systems
They have developed a CPOE “Standard” including a requirement that organizations operating CPOE systems should demonstrate (via testing scenarios) to ensure that their CPOE system can alert physicians to at least 50% of common serious prescribing errors
Configuration elements of the CPOE system that are tested
duplicate ordering
single and cumulative dose levels
allergy checking
drug-drug interaction
contraindications based on the diagnosis
contraindications based on lab values
dose levels based on radiology studies
Health IT Safety Tools and Resources
These are tools that provide excellent information for those in charge of health IT safety with varying levels of expertise
Health IT Safety Tools and Resources used by HIT safety persons
AHRQs Guide to Reducing Unintended Consequences of EHRs
SAFER Guides
CPOE Design Checklist
CPOE Pick-List Checklist
AHRQs Guide to Reducing Unintended Consequences of EHRs
An online resource designed to help organizations anticipate, avoid, and address problems that can occur when implementing and using an EHR
● Its purpose is to provide practical knowledge, troubleshooting
tools and resources.
AHRQs Guide to Reducing Unintended Consequences of EHRs
It provides multiple resources and addresses both future and current EHR users
Provides information on how to survive a system downtime and
includes a copy and paste toolkit as organizations struggle to
address the complexities of allowing this functionality in EHRs
SAFER guides
A guide that consists of nine guides organized into 3 categories
SAFER guides
These guides enable healthcare organizations to conduct self-assessments of their EHR safely in a variety of areas.
The guides identify recommended practices to optimize the safety and safe use of EHRs
3 types of SAFER guides
Foundational Guides
Infrastructure Guides
Clinical Process Guides
High Priority Practice
Identifies high risk and high priority recommended safety practices intended to
optimize safety and safe use of EHRs
Organizational Responsibilities
Identifies individual and organizational responsibilities intended to optimize safety and safe use of EHRs
Contingency Planning
Identifies recommended safety practices associated with planned or unplanned EHR unavailability instances in which clinicians or
other end users cannot access all part or part of the EHR
System Configuration
Identifies recommended safety practices associated with the way EHR hardware and software are set up
System Interfaces
Identifies recommended safety practices intended to optimize the safety and safe use system-to-system interfaces between EHR-related software applications
Patient Identification
Identifies recommended safety practices associated with the reliable identification of patients in the EHR
CPOE with DS
Identifies recommended safety practices associated with CPOE and CDS
Test Results Reporting and Follow up
Identifies recommended safety practices intended to optimize the safety and safe use of processes and EHR technology for the electronic communication and management of diagnostic test results
Clinician Communication
Identifies recommended safety practices associated with communication between clinicians and is intended to optimize the safety and safe use of EHRs
CPOE Design Checklist/Pick-List Checklist
These are two additional checklists that address health IT safety and provide tools for evaluating a current EHR
Includes checklist for configuring a CPOE system and creating Pick lists, or drop-down lists that are based on published health IT safety evidence.
CPOE Design Checklist
Is a 46 item list and provides a tool that can be used during software selection, design or evaluation
Items in the CPOE Design Checklist that fall into 4 categories
○ Clinical Decision Support (CDS)
○ Order From Configuration
○ Human Factors Configuration
■ Focuses on design system for safe human use
○ Workflow Process Configuration
■ Involves steps in how work is performed
Pick List Checklist
● Used by all levels of informatics specialists to assess current configuration based on the best evidence available
Pick List Checklist
An easy-to-use checklist such as this has multiple benefits and represents a starting point for informatics specialists to evaluate and improve the systems that care providers rely on to deliver safe patient care
