Health Affairs Issue on Patient Safety

The November issue of Health Affairs sponsored by the Gordon and Betty Moore Foundation, explores how hospital work environments can impact safety and how the use of health information technologies can be upgraded to reduce medication errors. Researchers need to study how electronic health records can affect safety not only in hospitals but also in the general healthcare provider environment.

Speaking at the Health Affairs briefing on November 6, 2018, Rear Adm. Jeffrey Brady M.D, Director of AHRQ’s Center for Quality Improvement and Patient Safety,   noted, “AHRQ has provided funding for studies as some of the brightest minds in research are part of the effort to improve patient safety. This growing momentum signals a sharpening focus on how to significantly reduce the risks of patient harm.”

A research article in the Health Affairs issue, titled “Identifying Electronic Health Record Usability and Safety Challenges in Pediatric Settings” by Raj M. Ratwani of MedStar Health’s National Center for Human Factors in Healthcare plus coauthors, analyzed 9,000 pediatric patient safety event reports related to EHRs and medication errors obtained from three different healthcare institutions. They found that 36 percent had an EHR usability issue that contributed to the medication error.

Some of the challenges to pediatric safety is that EHR system feedback concerned the usability challenge (82.4 percent), followed by visual display (9.7 percent), data entry (6.2 percent) and workflow support (1.7 percent). The most common medication error involved the improper dosage for the medication which was (84.5 percent).

The study suggests that the HHS Office of the National Coordinator for Health Information Technology, should include safety as part of the certification criteria for the use of EHRs with children. They further recommend that vendors and providers use rigorous test-case scenarios based on realistic clinician tasks to evaluate product functions. They also suggest that the Joint Commission should assess EHR safety as part of the hospital’s accreditation program.

Another article “An Electronic Health Record-Based Real-Time Analytics Program for Patient Safety Surveillance and Improvement” authored by David Classen Professor of Medicine in the Division of Clinical Epidemiology, University of Utah School of Medicine in Salt Lake City worked with several co-authors on the study.

The article points out that problems in accessing high quality data, the lack of data standards, and a shortage of experts with experience in analyzing data effectively is a pressing concern and will become even more serious as the promise of big data, machine learning, and artificial intelligence moves forward.

The researchers worked together to study how to more effectively analyze and improve the use of data using a novel method to extract safety indicators from EHRs to identify harm. The Patient Safety Active Management (PSAM) system pilot was initiated at two large community hospitals and researchers found that the PSAM could detect harm in real-time at higher rates than current levels are able to detect and that harm could be predicted..

AHRQ has made an ongoing commitment to lead national efforts to improve safety for patients”, according to Dr. Brady. To move forward on safety issues, Dr. Brady is Co-Chairing the National Steering Committee for Patient Safety a group established earlier this year to develop a national action plan to reduce patient harm. The committee is also Co-Chaired by Tejal Gandhi, M.D, Chief Clinical and Safety Office of the Institute for healthcare Improvement.

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