With advancements in technology and improvements in functionality comes an increased risk in patient safety. Systems are continuously being upgraded and configured to address the latest improvements. With each change there is potential for unexpected glitches, causing the system to possibly behave incorrectly or differently than previously utilized by its users. New workflows may be required within the organization and existing ones may need to be re-visited. This can lead to data being entered incorrectly or not captured at all. One recent case involved an Ebola patient being released when quarantine was required, potentially exposing other patients and individuals upon release. Upgrades to software versions may display risks in a different manner and become confusing to the individual entering data. Unfortunately, this can jeopardize patient safety.
Electronic healthcare has been a growing business and vendors are continuously offering new applications and add-ons. They are created and offered for different EHR systems and may or may not work as intended with each new upgrade. There are many vendors and products in the industry which causes an unfortunate problem where many disparate systems are unable to communicate with one another.
It becomes more important to ensure each organization is prepared for roll-outs with careful planning. Strategies need to be in place to prepare for these changes. Training should be created, detailed, and documented to ensure end-users are trained on newer versions, as well as being trained on each new application and feature that will be used. This applies to current employees and new-hires.
Researchers evaluated 100 closed safety investigations reported between August 2009 and May 2013 to the Informatics Patient Safety Office of the Veterans Health Administration. Among the findings, 74 events resulted from unsafe technology, such as system failures, computer glitches, false alarms or “hidden dependencies,” a term for what happens when a change in one part of a system inadvertently leads to key changes in another part. Another 25 events involved unsafe use of technology such as an input error or a misinterpretation of a display.
Universally, organizations have devised aggressive timelines to implement new systems and features in order to meet federal requirements for meaningful-use goals. Unfortunately, this may lead to improper planning, testing and training. Patient safety becomes compromised in these situations and puts healthcare networks at risk for penalties. SAFER Guides is a recommended list of various implementation and monitoring resources.
See Modern Healthcare “Complicated, confusing EHRs pose serious patient safety threats”
See HealthIT.Gov for additional information and resources.