Responding to health information technology reported safety events: Insights from patient safety event reports

Abstract

Objective: We analyzed the described resolutions of patient safety event reports related to health information technology to determine how healthcare systems responded to these events, recognizing that certain types of solutions such as training and education have a limited impact. Methods: A large database of over 1.7 million patient safety event reports was filtered to include those identified by the reporter as being related to health information technology. The resolution text was manually reviewed and coded into one or more of four categories: No Resolution, Training/Education, Policy, Information Technology-oriented solution. Results: Most events (64%) did not include a resolution. Of those that did, Training/Education was the most commonly reported single or component of a multi-pronged solution (55%), followed by Information Technology (45%). Only 59 events (6% of resolutions) described more than one method of resolution. Conclusion: Health information technology-related patient safety event resolutions most often described a solution that suggested additional training or education for healthcare staff, despite the recognized limitations of training and education in resolving these events. Few events suggested multiple resolution methods. Ensuring health information technology-related events are resolved and incorporate effective solutions should be a continued focus area for healthcare systems.

Identifying boundary spanning reporter roles in patient safety events

“…First, previous research has highlighted the limitations of self-reported data that are applicable to the voluntary PSE reports studied in this analysis. 23 Secondly, since the PSE reports included in this analysis were derived from a single reporting system for hospitals based in the Mid-Atlantic region of the United States, our findings may not be generalizable across different geographic contexts. The nearly 82,000 PSE reports included in this analysis were, however, derived from hospital sites that did vary in other important ways such as teaching status, size, and whether sites served both urban and suburban patient populations.…”

Patient Safety Issues Continue to Plague American Hospitals

“…Another area of concern related to patient safety is health information technology (IT). Researchers from MedStar Health's National Center for Human Factors in Healthcare and Georgetown University's School of Medicine recently analyzed 1.7 million patient safety events involving health IT . The researchers categorized responses according to one of four groups: no resolution, training and education, policy, and IT‐oriented solutions.…”

Time to take a breath: Rebalancing the human and technical aspects of patient safety

“…14 Adams et al analyzed a large database to investigate how healthcare systems handled patient safety events related to Health Information Technology. 15 They found that nearly two-thirds of events had not been resolved at the time of reporting. Perhaps more important, they noted that the majority of the recommendations were for training and education of providers, types of solutions known to have limited impact.…”