ONC: Poor documentation mars adverse event reporting

An analysis of adverse events reported to two databases found a need for improved reporting, according to a blog post at Health IT Buzz.

The report, released by the Office of the National Coordinator for Health IT, studied the databases of two patient safety organizations (PSOs), UHC and ECRI Institute, and the structured data from the Common Formats in their reporting systems.

In the ECRI database, only 4 percent of reported events had a response in the yes/no fields relating to whether health IT was involved, with most responses in narrative text.

The yes/no questions were answered about half the time in the UHC database, providing a larger set of records for analysis.

Medication-related errors were the most common health IT-related event type, about one-third of events, while more than half of the health IT-related events were categorized as "other," making it hard to determine exactly what they were.

About 60 percent of the events involving health IT were categorized as an incident (they reached a patient, though they might not have resulted in harm to the patient), 14 percent as near-miss events and 26 percent as an unsafe condition. The most common contributing factors were communication among staff and team members, followed by staff inattention, accuracy of data and availability of data.

At the same time, the analysis of the UHC data found that an estimated 31 percent of the events coded as health IT-related in fact were not, and more than 25 percent of the events that were health IT-related were not coded as such.

Creating a national surveillance center to monitor health IT-related patient safety events is one of the goals of the federal health IT safety center that the ONC is setting up.

In October, the ONC awarded a contract to Research Triangle Park, N.C.-based RTI International to design a roadmap for the health IT safety center, which is due by April 2015.

To learn more:
- read the blog post
- check out the report

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