Analysis and Mitigation of Reported Informatics Patient Safety Adverse Events at the Veterans Health Administration

Taylor, Lesley; Wood, Scott D.; Chapman, Roger J.

doi:10.1518/hcs-2012.945289401.001

Cited by 6 publications

(11 citation statements)

References 12 publications

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“…A solution for ‘low score’ incidents, although not mandatory, may be considered depending on available resources; for ‘intermediate score’ incidents, a solution such as training or request for software modification is mandatory; for ‘high score’ incidents, an immediate action, such as a software patch or safety notice to affected users, is required. After analysis, the IPS makes recommendations to software developers, individual medical facilities, or other relevant stakeholders within the VA healthcare system to mitigate the risk of error or harm 42. Investigation-related information is maintained in a database and tracked until the investigation is ‘closed.’ The final closed investigation for each report contains a narrative of the reported incident, the details of the investigation conducted by IPS and IT staff, and any solution that might have been identified.…”

Section: Methodsmentioning

confidence: 99%

An analysis of electronic health record-related patient safety concerns

Meeks

Smith

Taylor

et al. 2014

J Am Med Inform Assoc

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173

115

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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.

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Section: Methodsmentioning

confidence: 99%

An analysis of electronic health record-related patient safety concerns

Meeks

Smith

Taylor

et al. 2014

J Am Med Inform Assoc

Self Cite

173

115

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“…119 issues were reported between October 1st 2013 and September 30th 2014. 97 of these were considered patient safety risks and coded with PSI-CAM categories as part of the overall IPS patient safety issue analysis process (Taylor, Wood, and Chapman, 2012). This process involves storing information about the reported problem in a tracking database, including investigation & analysis, risk assessment, and proposed solutions.…”

Section: Methodsmentioning

confidence: 99%

“…One of the functions of the Veteran Health Administration's (VHA's) Informatics Patient Safety (IPS) Office is to investigate the reported use of Health Information Technologies (HITs) associated with adverse events (Leape, 2002). When a HIT safety concern is reported to IPS, a Safety Analyst reviews the report and conducts an investigation to gather more information about what happened, almost happened, or could happen (Taylor, Wood, and Chapman, 2012). Understanding of the cognitive factors that can contribute to adverse events during the use of HITs is critical for full identification of contributing causes and optimal solutions.…”

Section: Analysis Of Reported Health Information Technologies (Hits) mentioning

confidence: 99%

“…Traces such as this are normally created by the IPS Human Factors Specialist after the IPS Analyst conducts the initial analysis and produces a draft report. In preparation for discussion of the overall risk to patients the Human Factors Specialist will also use this table to document relevant information found in the Analyst's report about the three factors IPS considers when conducting a risk assessment -potential or actual severity of harm, frequency of the issue, and detectability of the issue (Taylor, Wood, and Chapman, 2012).…”

Section: Analysis Of Reported Health Information Technologies (Hits) mentioning

confidence: 99%

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A Cognitive Analysis of Informatics Patient Safety Issues Reported Within the Veterans Health Administration

Chapman¹,

Taylor

2015

Proceedings of the International Symposium on Human Factors and

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The goal of the Veterans Health Administration (VHA) Informatics Patient Safety program (IPS) is to improve the safety of Health Information Technology (HIT) products. To support the analysis of patient safety issues, a set of categories was developed for Human-HIT interaction errors that can occur as users conduct their work (Chapman, Taylor, and Wood, 2012). Here we describe the categorization of 97 patient safety issues reported to IPS between October 1st 2013 and September 30th 2014. We highlight: (1) how categorization can contribute to the risk assessment process, (2) which error types were most frequently found, and (3) how these results suggest the categories and our issue analysis process can be refined.

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“…When a patient safety issue is reported to IPS a Patient Safety Analyst reviews the initial report and then conducts an investigation to gather more information about what happened or almost happened (Taylor, Chapman, & Wood, 2012). This involves working with Department of Veterans Affairs (VA) system developers to better understand the software design and, where applicable, replicate the issue and document the user interactions with screen captures when possible.…”

Section: Analysis Of Reported Patient Safety Issuesmentioning

confidence: 99%

Cataloging Errors From Reported Informatics Patient Safety Adverse Events

Chapman¹,

Taylor²,

Wood³

2012

Proceedings of the 2012 Symposium on Human Factors and Ergonomics in Health Care

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An effective feedback mechanism to enable Health Information Technology (HIT) users and other stakeholders to report adverse events that occur after system deployment is an essential line of defense against risks to patient safety (Billings, 1999). The goal of the Patient Safety Informatics-Cognitive Analysis Model (PSI-CAM) project is to develop a practical theory-based framework to aid adverse event analysis and to apply it to patient safety issues reported to the Informatics Patient Safety (IPS) Office of the Veterans Health Administration (VHA), Department of Veterans Affairs (VA). This framework is based on a user-centered model of human interaction with technologies (Norman, 1986) and as such it helps ensure the analysis includes consideration of the relationship between the user-technology interface and the adverse events reported. Here we describe the framework and illustrate its use with real-world examples of issues reported to the VHA IPS Office.

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Analysis and Mitigation of Reported Informatics Patient Safety Adverse Events at the Veterans Health Administration

Cited by 6 publications

References 12 publications

An analysis of electronic health record-related patient safety concerns

An analysis of electronic health record-related patient safety concerns

A Cognitive Analysis of Informatics Patient Safety Issues Reported Within the Veterans Health Administration

Cataloging Errors From Reported Informatics Patient Safety Adverse Events

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