In November 2011, the Institute of Medicine released the report, “Health IT and Patient Safety: Building Better Systems for Better Care.” The report looked at the effects of health IT on patient safety. Most health IT professionals would say technology has the potential to improve patient safety—think bar coded medications and improved legibility of physician orders entered electronically. But the IOM had a bit of a plot twist with its report. While it acknowledged health IT has the potential to improve patient safety, it also can lead to patient harm if technologies are not properly designed and implemented.
In fact, the parents of an infant who died in 2010 after a series of medical errors at a Chicago-area hospital were recently award an $8.25 million settlement. Human error played a part in the incident when a pharmacy technician incorrectly entered information when processing an electronic IV order. But, the health IT back-up also failed. According to an article in the Chicago Tribune, the IV compounding machine’s automated alerts should have flagged the error, but the alerts weren’t activated when the IV bag was prepared.
In light of incidents like that one, The IOM recommended greater oversight of health IT by the public and private sectors.
The Office of the National Coordinator for Health Information Technology is now heading up the charge to improve health IT and patient safety. In December, it released its “Health IT Patient Safety Action and Surveillance Plan” for public comment.
In the report, the ONC acknowledges that when the IOM made its recommendations on patient safety and health IT there was “‘little published evidence’ quantifying the magnitude of risks associated with HIT.” Also, because health IT is becoming more and more entwined in health care delivery, it’s often difficult to determine whether and to what extent health IT contributes to errors.
For example, if a medical error could have been prevented by more sophisticated or improved implementation of CPOE, should that be considered a health IT-related error? Or, as in the Chicago-area case, if a clinician doesn’t use certain health IT functionality that could have prevented an error because the functionality was frustrating or inefficient to use, how should that error be categorized?
To address patient safety, the ONC’s draft “Health IT Safety Plan” has two objectives:
- Promote the health care industry’s use of health IT to make care safer.
- Continuously improve the safety of health IT.
To do this they have laid out action steps, including:
- Making it easier for clinicians to report patient safety events and risks using EHR technology
- Engaging health IT developers to share responsibility for patient safety and promote reporting of patient safety events and risks
- Providing support to patient safety organizations to identify, aggregate, and analyze health IT safety event and hazard reports
- Incorporating health IT safety in post-market surveillance of certified EHR technology through ONC-Authorized Certification Bodies
- Using Meaningful Use of EHR technology to improve patient safety
- Incorporating health IT safety into health care provider education and training
- Supporting research and development of testing, user tools, and best practices related to health IT safety and its safe use
Assessing, improving and developing a health IT patient safety standard isn’t a one man show. The IOM and ONC both stress it is a collaborative effort between the public and private sector. With that in mind they are asking for public comment on the draft from:
- Care Delivery Organizations
- IT staff
- Quality improvement staff
- Patients and their caregivers
- Federal and state governments
- Health IT developers
- Patient safety organizations
- Accrediting bodies
- Liability insurers
- Educational organizations
- Health insurers
- Professional associations
Now is the time for you to speak up. The ONC is accepting public comments on the Health IT Safety Plan through February 4, 2013. Comments can be emailed to ONC.Policy@hhs.gov. Based on the public comments, the ONC will publish the final Health IT Safety Plan. ♦
Jennifer Thew, RN, MSJ
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