Cultural of safety related to health information and technology

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Question Description

For this discussion, you will address the following:

  • Review the attached article, paying particular attention to the case study on p. 13
  • First, identify the two types of IT-related incidents
  • Briefly describe the situation in the case study
  • What type of IT incident is seen in this case study?
  • What were the potential consequences to the patient in this case study?
  • How can nurse leaders establish a culture of safety related to health IT?

Your initial post must be posted before you can view and respond to colleagues, must contain minimum of two (2) references, in addition to examples from your personal experiences to augment the topic. The goal is to make your post interesting and engaging so others will want to read/respond to it. Synthesize and summarize from your resources in order to avoid the use of direct quotes, which can often be dry and boring. No direct quotes are allowed in the discussion board posts.

References:

  • Initial Post: Minimum of two (2) total references: one (1) from required course materials and one (1) from peer-reviewed references.

Words Limits

  • Initial Post: Minimum 200 words excluding references (approximately one (1) page)

Unformatted Attachment Preview

Anticipating Unintended Consequences of Health Information Technology and Health Information Exchange How to Identify and Address Unsafe Conditions Associated with Health IT November 15, 2013 Authors Prepared for ECRI Institute: Cynthia Wallace, CPHRM The Office of the National Coordinator for Health Information Technology Karen P. Zimmer, MD, MPH, FAAP Washington, DC Lorraine Possanza, DPM, JD, MBE Robert Giannini, NHA, CHTS–IM/CP Ronni Solomon, JD Prepared by Westat 1600 Research Boulevard Rockville, MD 20850-3129 (301) 251-1500 Contract No: HHSP23320095655WC Task Order: HHSP23337003T Table of Contents Chapter Page Introduction .............................................................................................................................. 1 Health IT Overview ................................................................................................................. 3 Socio-Technical Model ...................................................................................... 5 Common Health IT-Related Problems ................................................................................. 6 Computer-Related Issues................................................................................... Human-Computer Issues .................................................................................. 9 10 Identifying Health IT’s Unintended Consequences ............................................................ 11 High-Reliability Organizations’ Commitment to Health IT Safety ............. Event Reporting within a Safety Culture ........................................................ 12 13 How to Collect Health IT Event Data.................................................................................. 14 Educating Staff About Health IT Event Reporting ...................................... What to Include in a Health IT-Related Event Report................................. AHRQ Common Formats for Health IT Event Data .................................. Beyond the Common Formats: Hazard Manager.......................................... Health IT Event and Hazard Analysis ............................................................ 14 14 15 16 17 Staff Feedback and Monitoring .............................................................................................. 20 Other Sources of Information for Health IT-Related Issues....................... 20 Reporting Health IT Events to PSOs ................................................................................... EHR Developers’ Role in Assuring Patient Safety.............................................................. 20 22 Teaming Up With PSOs .................................................................................... 24 Conclusion ............................................................................................................................... 25 Resources ............................................................................................................................... 26 References ............................................................................................................................... 27 How to Identify and Address Unsafe Conditions Associated with Health IT ii Table of Contents (continued) Tables Page 1 What is Health IT? ............................................................................................. 4 2 Examples of Health IT-Related Incidents ...................................................... 7 1 Health IT Safety: A Shared Responsibility...................................................... 2 2 Socio-Technical Model for Health IT ............................................................. 5 3 ECRI Institute PSO Deep Dive Identifies Top Five Safety Issues from Health IT Events ...................................................................................... 8 4 Continuous Feedback Approach to Health IT System Safety ..................... 12 5 Sample Screenshot from AHRQ’s Hazard Manager ..................................... 17 6 Case Study of a Laboratory Event Involving Health IT ............................... 19 7 Intended Flow of Patient Safety Event Data and Feedback ........................ 23 Figures How to Identify and Address Unsafe Conditions Associated with Health IT iii Introduction Health information technology (IT) can provide multiple benefits to enhance patient care if the technology is optimally designed by the system developer, thoughtfully implemented by the healthcare organization, and appropriately used by the organization’s staff. Health IT’s potential can also be undermined by the hazards created when a health IT system operates in unintended and unanticipated ways. For example, studies have found that the same health IT systems can have varied results when implemented in different facilities. In its 2011 report Health IT and Patient Safety: Building Safer Systems for Better Care, the Institute of Medicine (IOM) cites three studies conducted at different children’s hospitals that adopted the same computerized provider order entry (CPOE) system. In one hospital, the mortality rate did not change (Del Beccaro, Jeffries, Eisenberg, & Harry, 2006); however, in the other hospital, CPOE implementation led to a significant increase in mortality (Han et al., 2008). And when that same system was used in several other hospitals, mortality rates either did not change or dropped (Longhurst et al., 2010). According to IOM’s report (IOM, 2011), “The differing impact on mortality rates may be due to the hospitals’ differences in the implementation and use of the CPOE system.” “Designed and applied inappropriately, health IT can add an additional layer of complexity to the already complex delivery of health care, which can lead to unintended adverse consequences,” says IOM. Adding to the complexity is the challenge of recognizing the technology’s involvement in patient safety incidents and near misses—i.e., patient safety issues that are caught before they reach the patient. An electronic health record (EHR) system developer recently notified its customers that a software glitch in its emergency department module prevented emergency physicians’ notes about medications from transferring to the patients’ charts (U.S. Food and Drug Administration [FDA], 2013). Healthcare organizations may have viewed any incidents that occurred as a result of the bug as a medication omission, unaware that a software defect in the health IT system was at fault. A recent analysis of health IT-related events submitted by healthcare organizations to a federally certified patient safety organization (PSO) identified many of the common problems that can arise with health IT systems. The challenge for healthcare organizations is to detect the problems before the system is fully implemented. If a particular defect escapes detection, the organization must also have processes in place to identify those problems as soon as possible after the system is brought online. In short, healthcare organizations must operate as high-reliability organizations to ensure the safety of their health IT systems. Their safety culture should foster a willingness to learn about unsafe conditions with their health IT systems that can lead to patient harm and to make improvements to the systems before accidents do occur. To achieve their goals as high-reliability organizations in an increasingly wired healthcare environment, organizations must sharpen their internal processes to identify health IT flaws and How to Identify and Address Unsafe Conditions Associated with Health IT 1 make improvements. These processes must be ongoing because new safety risks can arise as software is upgraded and new interfaces are built. Organizations must also be able to call upon their EHR developers for assistance in addressing unanticipated system faults. As their customers expose the systems to the busy, complex healthcare environment, developers may find that their systems function within that environment in unexpected ways. They must be prepared to work with their customers to correct those bugs. But organizations should also be prepared to turn to other outside experts as the healthcare sector, collectively, gains experience with health IT and learns about the issues that can arise with the technology, as well as ways to ensure that health IT fulfills its promise of improved patient care. Within the protected and confidential framework offered by PSOs, healthcare organizations can also share with others their experiences with health IT systems to better understand problems that can occur with health IT systems and identify solutions. Additional guidance on health IT safety is available from federal and state healthcare safety oversight authorities, including various agencies of the U.S. Department of Health and Human Services—the Office of the National Coordinator for Health Information Technology (ONC), the Centers for Medicare and Medicaid Services, the Office for Civil Rights, and the FDA—and state licensing authorities. Ultimately, a healthcare organization’s approach to health IT safety relies on the collective guidance provided by internal and external experts ( see Figure 1). Working together, healthcare organizations, PSOs, EHR developers, and policymakers can learn how to achieve the full potential of health IT. Figure 1. Health IT Safety: A Shared Responsibility Healthcare Organizations Patient Safety Organizations Internal reporting of incidents, near misses, unsafe conditions Analysis of aggregated data, feedback, education Health IT Safety EHR Developers Safety alerts, software updates How to Identify and Address Unsafe Conditions Associated with Health IT Federal and State Authorities Guidance from agencies of the Department of Health and Human Services, as well as state licensing authorities 2 This White Paper is intended to help healthcare organizations lay the foundation for a process to identify health IT hazards, using both internal and external resources. It covers the following: 1. Describes health IT systems and addresses their operation within a complex healthcare environment. 2. Identifies five common health IT problems that can occur within the context of this complex environment and contribute to the unsafe use of health IT systems, leading to potential and actual patient harm. 3. Examines the role of organization’s internal reporting systems to identify and address unsafe scenarios for health IT systems and to continually monitor health IT systems’ safety and make improvements. 4. Discusses the role of external reporting programs, such as PSOs, in helping to identify areas for health IT system improvements. 5. Reviews the role of EHR developers in working with healthcare providers and external reporting programs to identify and manage health IT system improvements. Health IT Overview Broadly defined, health IT systems comprise the hardware and software that are used to electronically create, maintain, analyze, store, or receive information to help in the diagnosis, cure, mitigation, treatment, or prevention of disease (AHRQ, 2013a). For many healthcare organizations, health IT is synonymous with EHR, but it also includes various other components as depicted in Table 1. Numerous studies support health IT’s important role in patient safety. For example, CPOE systems can improve patient safety by eliminating transcription errors for illegible handwriting, providing clinical decision support, and alerting clinicians to potentially dangerous orders, such as a patient allergy to a selected medication (Kaushal, Shojania, & Bates, 2003). But studies also point to the so-called “unintended consequences” of health IT (Ash, Berg, & Coiera, 2004). Continuing with the CPOE example, studies have documented that, among several possible hazards with the systems, clinicians can mistakenly select the wrong patient file when placing an order in a CPOE system if the computer display is confusing, resulting in a medication order for the wrong patient. How to Identify and Address Unsafe Conditions Associated with Health IT 3 Table 1. What is Health IT? Health IT involves the exchange of health information in an electronic environment as in the following examples. Health IT System Administrative (e.g., medical billing and scheduling, practice management system) • • • Example Coding/billing system Master patient index Registration/appointment scheduling system Automated dispensing system • Medication dispensing cabinet Computerized medical devices • Infusion pumps with dose-error-reduction capability (i.e., “smart” pumps) Patient monitoring systems (e.g., cardiac, respiratory, fetal) • • • • Electronic health record (EHR) or EHR component • • • Bar-coded medication administration Clinical decision support system Clinical documentation system (e.g., progress notes) Computerized provider order entry Electronic medication administration record Pharmacy system Human interface device • • • • • • Keyboard Monitor/display Mouse Printer Speech recognition system Touchscreen Laboratory information system (including microbiology and pathology systems) • • • Microbiology system Pathology system Test results reporting Radiology/diagnostic imaging system • Picture archiving and communication system Adapted from “Device or Medical/Surgical Supply, Including Health Information Technology (HIT).” In Hospital Common Formats—Version 1.2: Event Descriptions, Sample Reports, and Forms, April 24, 2013. Rockville, MD: Agency for Healthcare Research and Quality. Retrieved August 20, 2013 from https://www.psoppc.org/web/patientsafety/version-1.2_documents. Indeed, health IT-related incidents can occur under any of the following circumstances (Sittig & Singh, 2011):  The system is unavailable for use.  The system malfunctions during its use.  The system is used incorrectly.  The system interacts incorrectly with another and causes the loss of data or data being incorrectly entered, displayed, or transmitted. How to Identify and Address Unsafe Conditions Associated with Health IT 4 Socio-Technical Model As with many events involving medical technology, health IT-related incidents, such as those described above, do not occur in isolation. The technology operates within a complex environment, and health IT must be considered in the context of that environment. In trying to understand why an event occurs, researchers have developed a socio-technical model for evaluating health IT within the context of eight dimensions (Sittig & Singh, 2010), as illustrated in Figure 2. Figure 2. Socio-Technical Model for Health IT Adapted by permission from BMJ Publishing Group Limited. Sitting DF and Singh H. A new socio-technical model for studying health information technology in complex adaptive healthcare systems. Quality and Safety in Health Care. 19(Supplement 3): i68-74, October 2010; doi: 10.1136/qshc.2010.042085 The eight dimensions of a socio-technical model for evaluating health IT are as follows: 1. Hardware and software (e.g., computers, keyboards, data storage, software to run health IT applications); 2. Clinical content (data, information, and knowledge stored in the system); How to Identify and Address Unsafe Conditions Associated with Health IT 5 3. Human-computer interface (hardware and software interfaces that allow users to interact with the system); 4. People (software developers, IT department personnel, clinicians, healthcare staff, patients, and others involved in health IT development, implementation, and use); 5. Workflow and communication (steps followed to ensure patients receive the care they need at the time they need it); 6. Internal organizational policies, procedures, environment, and culture (internal organizational factors, such as capital budgets, IT policies, and event reporting systems, which affect all aspects of health IT development, implementation, use, and monitoring); 7. External rules, regulations, and pressures (external forces, such as federal and state rules to ensure privacy and security protections and federal payment incentives to spur health IT adoption); and 8. System measurement and monitoring (processes to measure and monitor health IT features and functions). In short, examining health IT incidents within the context of the socio-technical model enables organizations to look beyond the incident to understand it in the context of the people who use the system and the other technologies and processes affected by health IT. Understanding these interactions enables high-reliability organizations to make improvements to their health IT systems when flaws in the systems are identified that can lead to patient harm. Common Health IT-Related Problems What are the most common problems that can occur with health IT systems? At the most basic level, there are two general areas. First, problems can occur at the interface between a computer user and the health IT system, causing a person to use the system incorrectly. Second, glitches can occur in how the equipment and software functions; for example, if software designed to connect one system to another has faulty coding, it could cause unexpected gaps in the transmitted data. Sample scenarios from each of these two categories, human-computer interface and computer-specific, are listed in Table 2. As organizations try to understand why a particular problem arose with their health IT systems, they can dissect these two general categories in greater detail. Did a problem at the human-computer interface occur when data was entered into the health IT system or when it was retrieved? Did the problem arise because the computer user was interrupted or distracted from a task? For computerspecific issues, the organization can explore an array of questions that could have caused the incident. Was there a power interruption to the healthcare facility’s computer network? Did information fail to display on the computer monitor? Was there a problem with the particular system’s software, hardware, or both? How to Identify and Address Unsafe Conditions Associated with Health IT 6 Table 2.   Examples of Health IT-Related Incidents Human-Computer Related A patient was not identified properly, and all clinical information was entered into the wrong record. Data were entered incorrectly into the electronic record due to multiple records being open.  Computer Related Data were not displaying properly in the system.  The network was down or slow.  Interface issues with the laboratory system caused delays in the ability to retrieve data.  The software was not up to date.  Software did not meet the needs of the specialty provider.  The system failed to alert the user of an identified concern with a flag or pop up.  The user ignored or overrode an alert.  Data were not entered into the system.  The software was not functioning properly.  Data were incomplete and missing from the entry.  Data were lost.   There was not enough equipment/devices for providers, causing delay in data entry. Internet or server connectivity issues prevented real-time data entry.   Lab test results were not reviewed in a timely manner. There was a breach in the security of the system (e.g., virus or malware).   An item from an outside source was scanned into the wrong patient record. Unapproved data-entry devices were used.  The hardware malfunctioned (e.g., mouse, keyboard, monitor, or touchscreen).  There was no evidence in the patient record of a written order or the care provided.  Data from th ...
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Running head: HEALTH INFORMATION TECHNOLOGY SAFETY CULTURE

HEALTH INFORMATION TECHNOLOGY SAFETY CULTURE.
Name
Course
Instructor
Institutional Affiliation
Date of Submission

1

HEALTH INFORMATION TECHNOLOGY SAFETY CULTURE.

2

Health Information Technology
There is uttermost satisfaction in knowing that your health is catered for efficiently, with
the invent of automated systems, wouldn’t you agree? Health Information Technology (HIT)
systems are a collection of the hardware and software entities that find their use in electronic
creation, maintenance analysis and retrieval of information for the purpose of diagnosis, cure or
prevention of diseases.
HIT is essentially synchronized with EHR (Electronic Health...

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