ONC issues guidance on reporting HIT-related safety issues

The Office of the National Coordinator for Health IT has issued guidance to help healthcare workers connect a clinical mishap or unsafe condition that could be related to an electronic health record.

The guide, "How to Identify and Address Unsafe Conditions Associated with Health IT," was developed by ECRI Institute under an ONC contract. It was designed to improve reporting of unsafe conditions--including by patient safety organizations and even IT developers--associated with health IT, and EHRs in particular, according to a Health IT Buzz blog post published this week by Kathy Kenyon, a senior policy analyst with ONC, and Steven Posnack, ONC's federal policy division director.

The guide urges use of two reporting tools, in particular--the Agency for Healthcare Research and Quality's (AHRQ) Common Formats (version 1.2) and AHRQ's Hazard Manager, which collects information about IT hazards via the Internet to create a central repository of data.

The guide also stresses the need for follow-up on reports. Patient safety organizations and EHR technology developers, in particular. can bring "analytical sophistication that helps tease out the complex 'sociotechnical factors' involved in health IT-associated events," according to the Kenyon and Posnack.

In a 2012 "deep dive" study of safety issues related to health IT, the ECRI Institute found underlying problems with EHR system interfaces, wrong input into EHRs, system configuration problems, wrong records retrieved, and software functionality issues.

The U.S. Department of Health & Human Services in July finalized its health IT safety plan, building on recommendations from a 2011 Institute of Medicine report, and from public comments. It planned activities to fall in three categories: learn, using reporting to identify problems; improve, by establishing and advancing health IT patient safety priorities; and lead, encouraging private-sector leadership and shared responsibility for patient safety.

Meanwhile, researchers from Dartmouth College and the University of Pennsylvania, saying electronic records tend to create their own "reality," last summer came up with 45 scenarios of miscommunication involving not just EHRs, but also physician order entry systems, pharmacy technology and other systems.

To learn more:
- here's the guide (.pdf)
- read the Health IT Buzz blog post

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