Promoting Patient Safety Through Effective Health Information Technology Risk Management

Promoting Patient Safety Through Effective Health Information Technology Risk Management

Eric C. Schneider
M. Susan Ridgely
Daniella Meeker
Lauren E. Hunter
Dmitry Khodyakov
Robert S. Rudin
Copyright Date: 2014
Published by: RAND Corporation
Pages: 77
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  • Book Info
    Promoting Patient Safety Through Effective Health Information Technology Risk Management
    Book Description:

    Health information technology (IT) has the potential to improve the safety of health care, but if not carefully implemented, health IT can also introduce new risks and even harm. The authors of this report evaluated the efforts of 11 hospitals and ambulatory practices to use an improvement strategy and tools developed to promote safe use of health IT and to diagnose, monitor, and mitigate health IT–related safety risks.

    eISBN: 978-0-8330-8978-6
    Subjects: Health Sciences, History

Table of Contents

  1. Front Matter
    (pp. i-i)
  2. Preface
    (pp. ii-ii)
  3. Table of Contents
    (pp. iii-iv)
  4. Tables and Figures
    (pp. v-v)
  5. Executive Summary
    (pp. vi-xiii)
  6. Acknowledgments
    (pp. xiv-xiv)
  7. Abbreviations
    (pp. xv-xv)
  8. 1. Background
    (pp. 1-2)

    The potential for electronic health records (EHRs) to improve the quality, safety, and efficiency of health care delivery has been recognized since the 1960s. The 1999 Institute of Medicine (IOM) reportTo Err is Humansuggested that health care delivery systems were not optimized to prevent avoidable medical errors.¹ Since the publication of that report, hospitals and other health care delivery organizations have focused on improving the reliability of processes to reduce medical errors and adverse events. EHRs have been an important cornerstone, especially because of their potential to mitigate errors through deployment of tools like clinical decision support (CDS)...

  9. 2. Implementation of Health IT Safety Risk Projects
    (pp. 3-7)

    Acknowledging the need for better information on the experience of organizations attempting to implement and improve health IT safety practices, ONC contracted with a team at the RAND Corporation (“RAND”), a nonprofit research organization; ECRI Institute (“ECRI”), a nonprofit research organization and patient safety organization (PSO); a and health informatics research experts at Baylor College of Medicine and the University of Texas to develop and evaluate a prototype approach for engaging hospitals and ambulatory practices in health IT safety risk identification and mitigation projects. The project had the following goals:

    1. Explore the challenges organizations face in deciding whether to...

  10. 3. Evaluation
    (pp. 8-11)

    A case study methodology was used to determine the extent to which the six-step process improvement strategy and associated resources were helpful to participating hospitals and ambulatory practices in identifying areas of risk, developing an improvement strategy, and ultimately mitigating risk.

    RAND identified six objectives for its case study– based evaluation:

    1. Describe the health IT safety risk areas prioritized by the individual sites and any factors associated with changes in priorities over time.

    2. Describe the role of health IT in the organization and the existing organizational health IT safety and risk mitigation strategies.

    3. Describe the health IT...

  11. 4. Results
    (pp. 12-37)

    As described in the previous two chapters, seven hospitals and four ambulatory sites completed the project, although three of the hospitals had limited engagement toward the end. Characteristics of the 11 participating sites are provided in Table 4.1. In four of the seven hospitals, projects were led by an individual in the risk management department; one of these individuals also had a position in the quality department. In two of the other hospitals, the projects were led by individuals in the quality department. The project in the final hospital was led by an individual in the IT department. The projects...

  12. 5. Lessons from the Pilot Project
    (pp. 38-45)

    Health care organizations in the United States are on an unprecedented pace to introduce and expand the use of new health IT systems in response to federal payment incentives. Strong evidence shows that health IT systems reduce some types of risks to patient safety. On the other hand, health IT also has the potential to introduce new types of patient safety risks, especially if poorly designed, implemented, or used. Given the effort to install and operate these health IT systems and their relative novelty, identifying and managing these new risks may be an afterthought for many organizations. The protocols for...

  13. 6. Discussion
    (pp. 46-51)

    It is a well-known systems engineering paradox that technical solutions designed to address safety problems frequently introduce new types of safety problems. The EHR that alerts physicians to trivially abnormal lab results may breed complacency and therefore cause them to miss serious abnormal lab results. As hospitals and ambulatory practices have been moving forward aggressively to implement health IT, this core paradox has not been prominently featured in their implementation plans. The introduction of health IT may be planting the seeds of a new set of patient safety risks, but awareness of these risks has been limited. This suggests the...

  14. References
    (pp. 52-53)
  15. Appendix: ECRI Institute PSO Adverse Event Analysis
    (pp. 54-61)