Healthcare systems' transitions from paper records to electronic ones are causing harm and in so many serious ways, providers are only now beginning to understand the scope.
Computer programs truncated dosage fields, leading to morphine-caused respiratory arrest; lab test and transplant surgery records didn't talk to each other, leading to organ rejection and patient death; and an electronic systems' misinterpretation of the time "midnight" meant an infant received antibiotics one dangerous day too late.
These are among the 171 health information technology malfunctions and disconnects that caused or could have caused patient harm in a report to the ECRI Institute's Patient Safety Organization. Thirty-six participating hospitals reported the data under a special voluntary program conducted last year.
Karen Zimmer, MD, medical director of the institute, says the reports of so many types of errors and harm got the staff's attention in part because the program captured so many serious errors within just a nine-week project last spring.
The volume of errors in the voluntary reports was she says, "an awareness raiser."
"If we're seeing this much under a voluntary reporting program, we know this is just the tip of the iceberg; we know these events are very much underreported."
The errors are classified, described, ranked, and analyzed in a 40-page "Deep Dive" report on health information technology errors. It documents with real cases what was described in a November, 2011 report from the Institute of Medicine, Health IT and Patient Safety: Building Safer Systems for Better Care.
As health systems rapidly move from paper to electronic records, upgrade their systems from one version to the next, or incorporate different vendors across various departments or service lines, mistakes are happening that are often go hidden for months and even years, Zimmer says.
A forgotten lab test that wasn't carried over, and nursing and system manager work-arounds that fail are commonplace. Human error happens when systems depend on people to manually enter information from one system to another.
"One health system did an upgrade of its health IT system, and down the line, realized a printout of a report omitted certain fields," added Cynthia Wallace, ECRI's Senior Risk Management Analyst. "They weren't aware of that until they needed to use those reports. They realized that an upgrade two years ago had caused the omission, and was never totally tested."
Zimmer says that this analysis "really highlights the importance of reporting. Because this affords us the chance to focus health systems' attention on these issues, and suggest some strategies."
One important message from these incidents, whether health systems are starting an electronic information technology system from scratch or introducing an add-on, or making any kind of change, is that they should spend time walking through three stages: planning, implementation and ongoing monitoring to review the workflow and processes. "This should not be a one-time checklist," Zimmer says, but a system for continuous checking to recognize what limitations are in the new system.
"If a system doesn't fully meet the (healthcare system's) needs, you don't want to leave an individual to come up with his or her own customized workarounds," she explains. "These are symptoms of suboptimal systems designs, and if you have a lot of them, you need to understand why staff adopt them and address their concerns."
The 36 hospitals that participated in the ECRI IT project are among the hospitals around the country for which ECRI serves as a Patient Safety Organization, or PSO.
PSOs are covered under a special federal law that allows hospitals to report incidents, near misses, and unsafe conditions immune from legal discovery and absent patient identification so those protections will encourage reporting of system and human mistakes without prompting blame, publicity, or litigation.
The 171 events documented, break down like this:
- 53% involved a medication management system.
- 25% involved a computerized order entry system
- 15% involved an electronic medication administration record
- 11% involved pharmacy systems
- 2% involved automated dispensing systems
- 17% were caused by clinical documentation systems
- 13% were caused by Lab information systems
- 9% were caused by computers not functioning
- 8%. Were caused by radiology or diagnostic imaging systems, including PACS
- 1% were caused by clinical decision support systems
Zimmer noted that errors are of two types:
- Those caused by humans and their interaction with electronic devices such as computers, such as when an operator fails to log off or retrieves the wrong patient record;
- Those caused by machines that move too slow, can't communicate, malfunction, and crash.
The human factor
The report blames 56% of the errors on computers, and 46% on humans' interface with those computers.
Zimmer noted that when healthcare systems convert from paper records to electronic ones, they often discard visual cues that staff have learned to rely on, resulting in confusion and mistakes.
For example, when a hospital emergency room went from paper to electronic records, it abandoned a white board, with big circles marked with an x, when doctors had used to signal to nurses when a patient should be discharged.
"Now, you don't have a whiteboard, you don't have the visual cue. It's now in a computer. And you need to let someone know where they could put this type of information so everyone in the ED would now have access to it," she says. "People don't realize that other people rely on these visual cues. You are truly changing the mode of communication when you go from paper to a computer screen," she says.
ECRI is currently evaluating a similar, and much larger list of reports from many of the 800 hospitals that contract with ECRI's PSO services.