The intent of the Health Information Technology for Economic and Clinical Health Act of 2009 and the Federal Health IT Strategic Plan was to stimulate the adoption of electronic health records (EHR) in order to improve patient outcomes. One report by the Office of the National Coordinator for Health Information Technology showed a significant increase in EHR adoption between 2008 to 2015. For example, the number of non-Federal acute care hospitals increased from 9.4 % in 2008 to 83.8 % in 2015.1
EHRs contain tools that augment patient care. For example, clinical decision support can detect drug allergies and contraindications. Transcription errors from illegible “hard-copy” orders are no longer an issue. Multiple providers can access a centralized patient chart at the same time.
Technologies that target each point of the medication-use process have been developed to reduce the likelihood of errors reaching the patient.2 These tools help healthcare providers prevent errors, enhance patient safety, and improve efficiency.
Even though EHRs minimize errors from occurring, new EHR-based errors have emerged. Literature has documented many cases of EHR related problems. Between January 2010 and June 2013, 120 health information technology-related sentinel events were reported to the Joint Commission.3 The majority of error were seen in the areas of human-computer interface (33%), workflow and communication (24%), and clinical content (23%).3
In this blog article, we will discuss the different types of EHR-associated errors.
System and software design related errors:
According to an article that was published in the Journal of Patient Safety in 2015, system and software design accounted for 15 % of all system-related issues that were reviewed/reported.4
Some examples include:
1- System selecting the wrong product during medication verification (long vs short acting insulin).
2- Missing dose range checking at the order entry level which could lead to barriers with smart pump optimization.
Besides errors from within the EHR, issues can arise from the interaction between the EHR and other technological solutions that are used for patient care (e.g. smart pump). In the April 2018 edition of the Institute for Safe Medication Practices (ISMP) report, ISMP surveyed more than 1,000 healthcare professionals who utilize smart pumps. ISMP used an 18-item smart pump survey in their study from November 2017 to January 2018. In the study population, More than 70% of respondents from larger hospitals ( ≥100 beds) and nearly half (45%) of respondents from smaller hospitals (< 100 beds) reported using smart pumps for more than 5 years, 22% of the larger hospitals utilized smart pumps for 1-5 years, with a small pool (≤5%) used smart pumps for less than a year or not at all.5
According to the survey, technology challenges, such as deficiencies related to library use and programming workflow, lead to observed errors such as wrong rate errors for secondary infusions or IV line or channel mix-ups.5
A few of documented error rates from the survey were as follows 5:
- Delay in secondary infusions - 62%
- Wrong rate errors for secondary infusions - 36%
- Dose-rate confusion during pump programming - 46%
IV pump integration with the EHR is the next step approach to eliminate discrepancies between electronic health record orders and manual pump programming by healthcare professionals. Unfortunately, not all health care institutions have EHR-smart pump integration. In the 18-item ISMP survey, only 15% of respondents indicated EHR-pump interoperability.5
Prior to infusion pump integration with EHR; a local hospital’s nurse completed 17 steps to manually program a dopamine infusion. Integration has condensed the process to 7 steps and reduce the amount of time needed to program infusion devices by 25%.6 This is one example where bi-directional interoperability between pump and the EHR has proven beneficial.
System dysfunction or malfunction related errors:
In the article mentioned above 4, system dysfunction or malfunction accounted for 8% of all system-related issues. Unplanned downtime can lead to significant delays in patient care. Errors in ordering, transcription, dispensing, and documentation are very common during unplanned downtime. Downtime policies and procedures (P&P) need to document downtime patient care workflows and multi-department communication. These P&P need to be kept up to date to incorporate any system changes or new technology. A thorough P&P will help a pharmacy react to system outages and avoid common pitfalls.
Conclusion:
EHR systems can transform the way healthcare is delivered when these technologies are designed, implemented, and used appropriately. As we address certain type of errors with EHR utilization, other types of errors may arise. Increased awareness of EHR-related errors can lead to technological solutions that help pharmacy staff use these technologies effectively and safely.
Authors:
Published on behalf of the Inpatient Workgroup for the Clinical Application SAG:
Andrew Liu, Pharm.D., CPHIMS. Informatics Pharmacist. Rush University Medical Center. Chicago, IL
Butch Parks, B.S.Pharm., M.S. Senior Consultant. HealthmarkIT. Springdale, AR
Hesham Mourad, Pharm.D., BCPS, BCCCP, CPHIMS, Pharmacy Informatics Team Leader. Mayo Clinic. Jacksonville, FL
Kathy Yount, B.S.Pharm., R.Ph. Clinical Informatics Pharmacist. Deaconess Hospital. Evansville, IN
Marie-Elsie Ade, Pharm.D., M.H.A., M.S., BI. Director of Pharmacy. Baptist Health South Florida. Cutler Bay, FL
Paolo Valerio, Pharm.D. PGY-2 Health System Pharmacy Administration Resident. Allegheny General Hospital. Pittsburgh, PA
Raymond Chan, Pharm.D. Pharmacy IS Specialist. Sentara Healthcare. Virginia Beach, VA
References:
1- Adoption of Electronic Health Record Systems among U.S. Non-Federal Acute Care Hospitals: 2008-2015. Retrieved from: https://www.healthit.gov/sites/default/files/briefs/2015_hospital_adoption_db_v17.pdf. Accessed April12, 2018.
2- Mahoney CD, Berard-Collins CM, Coleman R, Amaral JF, Cotter CM. Effects of an integrated clinical information system on medication safety in a multi-hospital setting. Am J Health Syst Pharm. 2007 Sep 15;64(18):1969-77. PMID: 17823111
4- Graber ML, Siegal D, Riah H, Johnston D, Kenyon K. Electronic Health Record–Related Events in Medical Malpractice Claims. J Patient Saf. 2015 Nov 6. [Epub ahead of print]