Nurses have always been champions of patient safety. I'll never forget the patient care mistakes that I've made and witnessed in my career. Fortunately, none of them were life threatening, but nonetheless, they were regrettable and, given the right alerts or checks and balances, may have been prevented.
Today's healthcare environment is infused with information technology (IT) that's intended to streamline workflow, enhance decision making, and improve patient safety. Electronic health records (EHRs) hold much promise for mitigating errors, but we've learned that they can also have unintended consequences, including introduction of errors due to copying data from a previous record, or selecting the wrong patient while processing orders. Other causes may be due to more/new work for clinicians, unfavorable workflow issues, or problems related to paper persistence. Computerized provider order entry (CPOE) systems, while intended to provide point-of-care access to evidence for decision making, may instead introduce some of these unintended consequences.1
Clinical decision support (CDS) systems can also contribute to changes in work design, roles, and communication. (See page 4.) Work processes need to be carefully analyzed for potential detrimental changes before going live, and the EHR design should be tailored for patient safety and quality. Nurses and other caregivers can expect to feel the impact of more electronic and less face-to-face communication, and alternative communication channels and opportunities can be constructed.2
The current wave of EHR adoption has advanced at an accelerated pace. Many hospitals and health systems are rapidly implementing EHRs to take advantage of the incentive dollars provided by the HITECH Act to achieve “meaningful use,” which is intended to improve the quality, safety, and efficiency of healthcare. When well designed and effectively used, health IT can save lives, improve quality, and reduce costs. However, at the same time, concern has been raised that current market forces aren't adequately addressing the potential risks associated with use of health IT.
In its role as an advisor to our nation's health, the Institute of Medicine (IOM) published the report Health IT and Patient Safety: Building Safer Systems for Better Care. One of its key findings is that all stakeholders need to work together to improve patient safety. This is no surprise to nurses who traditionally work in teams to deliver patient-centered care. The IOM also found that system-level failures occur almost always because of unforeseen combinations of component failures.3 Further analysis of the current state of health IT shows that it may lead to safer care and/or introduce new safety risks.
As EHR adoption becomes more widespread, the incidence of health IT-related harm may also increase. At the same time, the increase in EHR adoption also creates a unique opportunity to improve patient safety. What are the potential benefits of using EHRs? For example, EHRs can:
- increase clinicians' awareness of potential medication errors and adverse interactions
- improve the availability and timeliness of information to support treatment decisions, care coordination, and care planning
- make it easier for clinicians to report safety issues and hazards
- give patients the opportunity to more efficiently provide input on data accuracy than what paper records would allow.3
One IOM recommendation was for the Secretary of Health and Human Services (HHS) to publish an action and surveillance plan that includes a schedule for working with the private sector to assess the impact of health IT on patient safety, thus minimizing the risk of its implementation and use. In response, the Office of the National Coordinator for Health IT (ONC) published the Health IT Patient Safety Action and Surveillance Plan to address the role of health IT within HHS' commitment to patient safety.4 This plan outlines specific actions that all stakeholders can leverage to improve the impact of health IT on patient safety. Nurses are key among stakeholders who can embrace and advance this action plan to maximize the safety of health IT.
When I was working as a clinical nurse at a local community hospital, a nurse on my unit administered a prescribed dose of Coumadin to her patient, forgetting to check the patient's current blood clotting time. Unfortunately the patient's clotting time was prolonged, and as a result of the oversight, the patient developed compartment syndrome from a bleed into the muscle of his right arm, which eventually led to his disability. This medication error could've been prevented if health IT, in the form of a closed loop bedside barcoding medication management system, was being used.
Although health IT has enormous potential to improve the quality and safety of healthcare, unintended consequences can happen any time, including long after EHR implementation. Even if rollout was well planned and executed, problems may emerge after the EHR is in effect on a daily basis. Developers and users of CPOE and CDS systems must ensure that these complex interactive functions are designed, tested, implemented, supported, and used correctly and safely. The Joint Commission has published the following list of recommendations for improving EHR safety:
- Actively involve clinicians and other staff in the reassessment and ongoing quality improvement of technology solutions.
- Continuously monitor for problems and address any issues as quickly as possible, particularly problems obscured by workarounds or incomplete error reporting.
- Use interdisciplinary brainstorming methods for improving system quality and giving feedback to vendors.
- Carefully review skipped or rejected alerts.
- Require departmental or pharmacy review and sign off on orders created outside the usual parameters.
- Provide an environment that protects staff involved in data entry from undue distractions when using the technology.
- Continually reassess and enhance safety effectiveness and error-detection capability, including the use of error tracking tools and the evaluation of near-miss events.
- Use manual or automated surveillance techniques to continually monitor and report errors and near misses or close calls caused by technology.
- Pursue system errors and multiple causations through root cause analysis (finding the real cause of the problem and addressing it rather than simply continuing to deal with the symptoms) or other forms of failure-mode analysis.5
As an outcome of the ONC Health IT Patient Safety Action and Surveillance Plan, The Joint Commission will soon build upon existing programs to better identify, understand, and investigate health IT-related deaths, serious injuries, and potentially unsafe conditions (sentinel events) in the private sector. It will also develop educational materials and training opportunities for healthcare providers. These resources will be welcome tools to help us, as stakeholders, better assess and mitigate potential unintended consequences of EHR and technology implementations.
Other resources soon to be available from the ONC are Safety Assurance Factors for EHR Resilience (SAFER) guides.4 These guides will comprise self-assessment tools, checklists, and best practices based on existing research, expert opinion, and stakeholder engagement. They're designed to enable those responsible for safety in health systems and ambulatory settings to implement health IT safety programs in critical areas, including:
- high priorities for health IT safety
- organizational activities and responsibilities
- system interfaces
- system configuration
- contingency planning
- patient identification
- CPOE with decision support
- test reporting and follow-up
- clinician communications.
Health IT can enable patients and families to participate in their care and become knowledgeable about conditions and treatments through the use of personal health records and online resources and portals. These tools can improve communication among healthcare providers, patients, and families, and facilitate shared decision making, but they may add another layer of complexity to the sociotechnical system, requiring nurses and other caregivers to be knowledgeable and techno-savvy resources for the patients they serve.
Health IT has a clear and demonstrated potential to improve patient safety, but it can also cause harm. All stakeholders must be aware of this dichotomy and seek to coordinate efforts to increase our awareness and understanding of the risks, and improve the safe design, implementation, and use of health IT. And most importantly, we must be mindful that our patients' lives depend on it.
1. Campbell EM, Sittig DF, Ash JS, et al. Types of Unintended Consequences Related to Computerized Provider Order Entry. J Am Med Inform Assoc
. 2006 Sep-Oct; 13(5): 547–556.
2. Staggers N., Weir C., Phansalkar S. (2008). Patient Safety and Health Information Technology: Role of the Electronic Health Record in Patient Safety and Quality: An Evidence-Based Handbook for Nurses
. Rockville (MD): Agency for Healthcare Research and Quality, 2008.
3. IOM (Institute of Medicine). 2012. Health IT and Patient Safety: Building Safer Systems for Better Care. Washington, DC: The National Academies Press.
5. The Joint Commission. Sentinel Event Alert: Safely implementing health information and converging technologies. Dec. 2008.