Improve Patient Safety through Electronic Health Records

Information management in EHRs tops the list of patient safety trouble spots. Using a few simple steps could drastically decrease the likelihood of a patient safety incident.

This article was originally published on June 29, 2017, on Association of Clinical Documentation Improvement Specialists.

Information management in EHRs tops the list of patient safety trouble spots, according to the Emergency Care Research Institute’s (ECRI) list of patient safety concerns for 2017, published in March.

Now, in response to this mounting problem, the Healthcare Information and Management Systems Society (HIMSS) Electronic Health Record Association outlined suggestions in a new report, “Electronic Health Record Design Patterns for Patient Safety,” to improve patient safety through the EHR,  Fierce Healthcare reports.

The report is divided into five sections with concrete improvement opportunities for each:

• Medications
• Alert fatigue
• Lab results
• Numeric display
• Displaying text

Though each section includes several suggestions, there are a few which appear especially relevant to CDI concerns, including:

• Differentiate an EHR alert’s intrusiveness by its importance
• Distinguish new test results from previous test results
• Use abbreviations sparingly and carefully
• Make the difference between “no value recorded” and “actually no value” clear

Every CDI professional knows that better documentation means better patient care and safety. By implementing some subtle changes and methodologies within the EHR, the report posits, the task becomes simpler.