A Guide: How to Identify and Address Unsafe Conditions Associated with Health IT

When front line clinicians confront a clinical mishap or unsafe condition in EHR-enabled healthcare settings (such as a medication error or a missed diagnosis) they may not connect the clinical event with how EHR use could have helped prevent it, how misuse or failure to use EHR functionality as intended contributed to the problem, or how weaknesses in EHR configuration, interfaces, or usability contributed.

To help clinicians and other EHR users address health IT-related safety issues, we have posted a guide and slide deck [PDF – 2.7 MB] [Powerpoint PPTX – 3.0 MB] called How to Identify and Address Unsafe Conditions Associated with Health IT, developed by ECRI Institute under an ONC contract.  The guide aims to help healthcare organizations and Patient Safety Organizations (and perhaps health IT technology developers, industry professional associations, and risk management and liability insurance companies) improve reporting of unsafe conditions associated with health IT, EHRs in particular.

This guide is one of a series of tools developed to addresses the potential unintended consequences of health IT as part of our commitment to improving health IT safety based on the Health IT Patient Safety Action and Surveillance Plan (Health IT Safety Plan).

Both the Health IT Safety Plan and the ONC-sponsored Institute of Medicine report on Health IT and Patient Safety: Building Safer Systems for Better Care External Links Disclaimer recognized the need for more reporting of health IT safety events and unsafe conditions, and urged a larger role for Patient Safety Organizations (PSOs), listed by AHRQ, in reporting and follow-up of errors and health IT related events.

In the past year, we have seen more and better results in identifying and classifying health IT-related safety issues.  The authors of How to Identify and Address Unsafe Conditions Associated with Health IT are from the ECRI Institute PSO, which in December 2012 published a “deep dive” research project on safety issues associated with health IT use.  As is generally true in health care, most of the reported safety events were related to medications and diagnostic information (labs and imaging).   What made the “deep dive” project different was that it pointed to “computer” and “human-computer” factors as underlying causes, with the most common problems being associated with EHR system interfaces, wrong input into EHRs, system configuration problems, wrong records retrieved, and software functionality issues.

We hope the guide published today will help stakeholders identify unsafe conditions with underlying health IT causes so they are more frequently reported.  The guide points to two standardized reporting tools that should help describe the role of health IT in adverse events and unsafe conditions, specifically AHRQ’s Common Formats (version 1.2) and AHRQ’s Hazard Manager.  These tools allow aggregation and comparison of health IT-related events and unsafe conditions over time.

This guide also addresses the need for follow-up on reports.  Busy people in healthcare (as in other fields) need feedback or they tend not to report.  The work of providing that feedback begins with healthcare organizations. However, when it comes to understanding health IT’s role in safety events, healthcare organizations may need help.   This guide describes how PSOs and EHR technology developers can help by, for example, bringing analytical sophistication that helps tease out the complex “sociotechnical factors” involved in health IT-associated events.  PSOs can also provide a legally protected space for reporting and follow-up, including the involvement of EHR developers.

Health IT safety is a shared responsibility.  In many ways, EHR users cannot optimize the safety and safe use of EHRs without help.  But we cannot realize that optimization until we have better evidence about the safety problems associated with health IT.  Getting that evidence requires being able to identify the underlying health IT causes of unsafe conditions in healthcare and reporting them

We don’t expect the discussion will end here or with this guide so feel free to add your thoughts and comments below. Additionally, to help stakeholders use the guide, we will be offering a webinar (details will be posted soon).


  1. Trudy Bearden says:

    Because failure to diagnose is the number one cause of malpractice suits (more important, harm to patients!), all clinicians should be tracking in-process lab orders. Orders for which results have returned should be autocompleted (should be a requirement of EHR certification!). Those that are not should be tracked down. Either the patient had done, and the clinician doesn’t have the results – go get results and enter as structured data. Patient didn’t have done – document contact with patient and reason not done. Clinician decided test was not needed – document reason. ALL EHRs should have the capability to do run reports of in-process orders with easy linking to the order and patient chart. Some EHRs permit an alert that is sent to the clinician if the result does not return within a given amount of time.

    We should leverage our EHRs to combat primary nonadherence (i.e., patient doesn’t fill the medication that the clinician prescribes). Primary nonadherence costs the healthcare industry billions and has implications with patient safety as well. Some vendors already notify prescribers if the patient fails to fill the prescription. Having this information is an excellent conversation starter to engage patients in their care. We can talk to them about why they didn’t fill their medication (too expensive, feeling better, no transportation, afraid of side effects, etc.). We can then help overcome barriers. I would love to see this required for Stage 3!!

    Because over-the-counter medications are not all innocuous, we should enter all OTCs and herbals into patients’ medication lists. For example, acetaminophen overdose is the number one cause of acute liver injury/failure and is included in NUMEROUS OTC meds. We clinicians often prescribe medications containing acetaminophen without knowledge of the patient’ total intake. This would also be great to include in Stage 3.

    The healthcare industry is unique in that consumers have no idea how much it will cost them to receive a service. As a big proponent of price transparency, I strongly believe EHRs should have the capability to display the cost of CPT codes that clinicians order. A recent study showed that showing the cost of lab tests resulted in a reduction in ordering certain tests by 19% (http://www.ncbi.nlm.nih.gov/pubmed/24257964 ). Any and all unnecessary tests pose a risk to patients. Perhaps if more EHRs had this capability, it would cut down on ordering tests that are not absolutely necessary. And, yes, this should be included in Stage 3, too.

    The evidence regarding cancer risk with increasing accumulation of radiation exposure is irrefutable at this point. There are two things we can do to protect our patients. First, the EHR can keep calculate and keep track of lifetime cumulative radiation exposure. Second, the EHR can capture as structured data whether radiation exposure was discussed as part of informed consent when clinicians order imaging with radiation. In fact, I’d like to see someone develop an app for patients to keep track of this using CPT codes for the tests!! And we could do this for Stage 3, too.

  2. LeoHolmMD says:

    I have submitted 2 complaints against our broken and buggy EHR that is so unstable it is dangerous. No response from your agency.

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