Health IT-Related Patient Safety Problems Seldom Resolved

In theory, health IT solutions are put in place to prevent errors from taking place, but sometimes they’re actually the cause of the error. Worse, in many cases these HIT-related safety problems are never resolved, according to a new research paper.

The study, which was conducted by three researchers with the National Center for Human Factors in Healthcare at Medstar Health, relied on a database of 1.7 million patient safety event reports. Researchers filtered the data to identify events related to health IT issues.

Once the HIT-related safety events were identified, the research team then reviewed and coded these events as falling into one of four categories: No Resolution, Training/Education, Policy or Information Technology-oriented solution.

Upon analysis, the researchers found that the majority of events (64%) didn’t include a resolution. Among events that were resolved, Training/Education was cited most often as a single cause or component of a multi-factor solution. Information technology came in second, accounting for 45% of solutions. Just 6% of resolutions cited more than one factor as having caused the problem.

The Medstar team seemed skeptical that these issues were being handled well, with most solutions being attributed to a lack of training or education in the healthcare staffer “despite the recognized limitations of training and education in resolving these events.”  Also, they seem to have concluded that the lack of events attributed to multiple causes wasn’t a good sign either.

As for me, I think it’d be important to know when such errors are most likely to happen. For example, I wouldn’t be surprised to learn that HIT-related patient safety issues are more common when a provider is switching from one platform to another.

That is apparently what happened, for example, at Phoenix-based health system Banner Health last year, where there were multiple reports of medical errors filed with the Arizona Department of Health Services after its Tucson-area hospitals cut over to a Cerner EHR.

It also seems like a given that there’s considerable potential for HIT-related patient safety errors due to overrides of clinical decision support alerts.  According to one 2018 study tracking CDS overrides in a group of ICUs for several months, 19% of medication-related overrides were scored as “inappropriate” by independent reviewers. These inappropriate overrides were associated with a greater risk of adverse drug events.

To be sure, some health IT-related errors are almost certainly attributable to gaps in clinician training. It simply stands to reason. However, if the Medstar researchers’ data is any indication, those classifying such events are sometimes failing to look at them in a nuanced way, and if their actions are representative of national norms we may have a problem here.

About the author

Anne Zieger

Anne Zieger

Anne Zieger is a healthcare journalist who has written about the industry for 30 years. Her work has appeared in all of the leading healthcare industry publications, and she's served as editor in chief of several healthcare B2B sites.

   

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