An analysis of electronic health record-related patient safety concerns

Abstract

ObjectiveA recent Institute of Medicine report called for attention to safety issues related to electronic health records (EHRs). We analyzed EHR-related safety concerns reported within a large, integrated healthcare system.MethodsThe Informatics Patient Safety Office of the Veterans Health Administration (VA) maintains a non-punitive, voluntary reporting system to collect and investigate EHR-related safety concerns (ie, adverse events, potential events, and near misses). We analyzed completed investigations using an eight-dimension sociotechnical conceptual model that accounted for both technical and non-technical dimensions of safety. Using the framework analysis approach to qualitative data, we identified emergent and recurring safety concerns common to multiple reports.ResultsWe extracted 100 consecutive, unique, closed investigations between August 2009 and May 2013 from 344 reported incidents. Seventy-four involved unsafe technology and 25 involved unsafe use of technology. A majority (70%) involved two or more model dimensions. Most often, non-technical dimensions such as workflow, policies, and personnel interacted in a complex fashion with technical dimensions such as software/hardware, content, and user interface to produce safety concerns. Most (94%) safety concerns related to either unmet data-display needs in the EHR (ie, displayed information available to the end user failed to reduce uncertainty or led to increased potential for patient harm), software upgrades or modifications, data transmission between components of the EHR, or ‘hidden dependencies’ within the EHR.DiscussionEHR-related safety concerns involving both unsafe technology and unsafe use of technology persist long after ‘go-live’ and despite the sophisticated EHR infrastructure represented in our data source. Currently, few healthcare institutions have reporting and analysis capabilities similar to the VA.ConclusionsBecause EHR-related safety concerns have complex sociotechnical origins, institutions with long-standing as well as recent EHR implementations should build a robust infrastructure to monitor and learn from them.

An analysis of electronic health record–related patient safety incidents

“…Controversial evidence about HIT safety shows that HIT-related errors have complex sociotechnical origins. [19][20][21][22] More information regarding EHR-related patient safety concerns is needed. Different patient safety data sources that complement each other are useful in identifying hazards and providing a more comprehensive view of the risks in a particular system.…”

Health information systems´ usability-related use errors in patient safety incidents

“…The HIS related usability issues identified in this study have also been addressed in prior studies. Information fragmentation into multiple views has been shown to be a common safety issue [5,6]. Use problems related to patient identification, selecting the wrong patient, and managing wrong patient data have occurred in earlier studies [5,7,9].…”

“…Previous studies have addressed various aspects of HISs that may cause safety issues [4][5][6][7][8][9][10]. Specifically, usability and use error related safety issues -the focus of this study -have also been identified in previous studies.…”

“…Johnson et al [4] indicated that the primary electronic health record (EHR) usability issues are poor organization and display of information, interference with practice workflow, increase in cognitive burden, and poor functional design. Some HIS use risks and safety concerns identified in previous studies include information passing and handling between different information systems, multiple screens and manual and electronic systems, finding and merging fragmented information, identification of valid and relevant information, and allowance of conflicting information input [5,6]. Other previously identified HIS usability or use error related safety issues are amongst other things the inconsistencies in used standards (e.g.…”

“…Other previously identified HIS usability or use error related safety issues are amongst other things the inconsistencies in used standards (e.g. units and date formats), wording and functions [5,6], patient identification issues [6,7,9], navigation difficulties [6,7], and wrong or missing data input [7,910]. To summarize, safety problems exist even in the context of broad experience in HIS implementations, and the increasing amount of implementations does not decrease the error rate.…”