EHR Design Flaws Contribute to Patient Harm in the ED
"You sigh, recalling the very low cross-reactivity between cefepime and penicillin. When you attempt to order vancomycin: 'Warning! The patient has an adverse reaction to vancomycin. You must enter a reason why you wish to proceed with your order of vancomycin.'
" 'What's that?' you think to yourself. 'Didn't we just do this?' You click to get past the pop-up and order the antibiotic anyway. An hour later, a nurse has turned off the vancomycin infusion, asked you to order diphenhydramine, and is filing an incident report about a preventable adverse medication reaction."
The report lists seven recommendations, some of which are directed at emergency department information system vendors. They are:
1. Each ED should have a clinician champion to lead a performance improvement group.
2. Such a group should be multidisciplinary, and meet regularly to communicate with ED and hospital leadership.
3. There should be a review process to monitor patient safety issues involving ED information systems, and providers and others should be encouraged to submit safety concerns for review.
4. Providers, vendors, and hospital administrators should address those concerns in a timely manner, with "full transparency, specifically with openness, communication, and accountability."
5. Lessons learned should be measured and shared publicly, including with other EDs using the same information systems.
6. Vendors should learn from patient safety improvements and ensure timely distribution of necessary changes to all installation sites.
7. "Hold harmless" or "learned intermediary" clauses should be removed from vendor software contracts.
Cheryl Clark is senior quality editor and California correspondent for HealthLeaders Media. She is a member of the Association of Health Care Journalists.
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