The effects and preventability of 2627 patient safety incidents related to health information technology failures: a retrospective analysis of 10 years of incident reporting in England and Wales

Background The contribution of usability flaws to patient safety issues is acknowledged but not well-investigated. Free-text descriptions of incident reports may provide useful data to identify the connection between health information technology (HIT) usability flaws and patient safety. Objectives This article examines the feasibility of using incident reports about HIT to learn about the usability flaws that affect patient safety. We posed three questions: (1) To what extent can we gain knowledge about usability issues from incident reports? (2) What types of usability flaws, related usage problems, and negative outcomes are reported in incidents reports? (3) What are the reported usability issues that give rise to patient safety issues? Methods A sample of 359 reports from the U.S. Food and Drug Administration Manufacturer and User Facility Device Experience database was examined. Descriptions of usability flaws, usage problems, and negative outcomes were extracted and categorized. A supplementary analysis was performed on the incidents which contained the full chain going from a usability flaw up to a patient safety issue to identify the usability issues that gave rise to patient safety incidents. Results A total of 249 reports were included. We found that incident reports can provide knowledge about usability flaws, usage problems, and negative outcomes. Thirty-six incidents report how usability flaws affected patient safety (ranging from incidents without consequence, to death) involving electronic patient scales, imaging systems, and HIT for medication management. The most significant class of involved usability flaws is related to the reliability, the understandability, and the availability of the clinical information. Conclusion Incidents reports involving HIT are an exploitable source of information to learn about usability flaws and their effects on patient safety. Results can be used to convince all stakeholders involved in the HIT system lifecycle that usability should be considered seriously to prevent patient safety incidents.

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Classifying Health Information Technology patient safety related incidents – an approach used in Wales

Applied Clinical Informatics ◽

10.4338/aci-2012-03-ra-0010 ◽

2012 ◽

Vol 03 (02) ◽

pp. 248-257 ◽

Cited By ~ 21

Author(s):

P. Edwards ◽

D. Warm

Keyword(s):

Information Technology ◽

Patient Safety ◽

Health Information Technology ◽

Health Information ◽

New Technologies ◽

Reporting System ◽

Incident Reporting ◽

Technical Problems ◽

Safety Incident ◽

Access Problems

SummaryInterest in the field of patient safety incident reporting and analysis with respect to Health Information Technology (HIT) has been growing over recent years as the development, implementation and reliance on HIT systems becomes ever more prevalent. One of the rationales for capturing patient safety incidents is to learn from failures in the delivery of care and must form part of a feedback loop which also includes analysis; investigation and monitoring. With the advent of new technologies and organizational programs of delivery the emphasis is increasingly upon analyzing HIT incidents.This thematic review had two objectives, to test the applicability of a framework specifically designed to categorize HIT incidents and to review the Welsh incidents as communicated via the national incident reporting system in order to understand their implications for healthcare. The incidents were those reported as IT/ telecommunications failure/ overload. Incidents were searched for within a national reporting system using a standardized search strategy for incidents occurring between 1st January 2009 and 31st May 2011. 149 incident reports were identified and classified. The majority (77%) of which were machine related (technical problems) such as access problems; computer system down/too slow; display issues; and software malfunctions. A further 10% (n = 15) of incidents were down to human-computer interaction issues and 13% (n = 19) incidents, mainly telephone related, could not be classified using the framework being tested.On the basis of this review of incidents, it is recommended that the framework be expanded to include hardware malfunctions and the wrong record retrieved/missing data associated with a machine output error (as opposed to human error).In terms of the implications for clinical practice, the incidents reviewed highlighted critical issues including the access problems particularly relating to the use of mobile technologies.

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Health Informatics in Developing Countries: A Review of Unintended Consequences of IT Implementations, as They Affect Patient Safety and Recommendations on How to Address Them

Yearbook of Medical Informatics ◽

10.1055/s-0038-1641611 ◽

2016 ◽

Vol 25 (01) ◽

pp. 70-72 ◽

Cited By ~ 1

Author(s):

A. Almerares ◽

D. Luna ◽

A. Marcelo ◽

M. Househ ◽

H. Mandirola ◽

...

Keyword(s):

Information Technology ◽

Developing Countries ◽

Patient Safety ◽

Health Information Technology ◽

Health Information ◽

Health Informatics ◽

Healthcare Organization ◽

Unintended Consequences ◽

Alert Fatigue ◽

Available Information

SummaryBackground: Patient safety concerns every healthcare organization. Adoption of Health information technology (HIT) appears to have the potential to address this issue, however unanticipated and undesirable consequences from implementing HIT could lead to new and more complex hazards. This could be particularly problematic in developing countries, where regulations, policies and implementations are few, less standandarized and in some cases almost non-existing.Methods: Based on the available information and our own experience, we conducted a review of unintended consequences of HIT implementations, as they affect patient safety in developing countries.Results: We found that user dependency on the system, alert fatigue, less communications among healthcare actors and workarounds topics should be prioritize. Institution should consider existing knowledge, learn from other experiences and model their implementations to avoid known consequences. We also recommend that they monitor and communicate their own efforts to expand knowledge in the region.

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Health information technology adoption: effects on patient safety and quality of care

International Journal of Healthcare Technology and Management ◽

10.1504/ijhtm.2015.070519 ◽

2015 ◽

Vol 15 (1) ◽

pp. 31 ◽

Cited By ~ 2

Author(s):

Binyam K. Seblega ◽

Ning Jackie Zhang ◽

Thomas T.H. Wan ◽

Lynn Y. Unruh ◽

Anastasia Miller

Keyword(s):

Information Technology ◽

Patient Safety ◽

Quality Of Care ◽

Technology Adoption ◽

Health Information Technology ◽

Health Information ◽

Information Technology Adoption

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Health Information Technology

Healthcare Administration ◽

10.4018/978-1-4666-6339-8.ch001 ◽

2015 ◽

pp. 1-22

Author(s):

Patrick Albert Palmieri ◽

Lori T. Peterson ◽

Miguel Noe Ramirez Noeding

Keyword(s):

Information Technology ◽

Patient Safety ◽

Organizational Development ◽

Health Information Technology ◽

Health Information ◽

Development Strategy ◽

Financial Viability ◽

System Failure ◽

Healthcare Organizations ◽

Safety Concerns

Healthcare organizations are increasingly willing to develop more efficient and higher quality processes to combat the competition and enhance financial viability by adopting contemporary solutions such as Health Information Technology (HIT). However, technological failures occur and represent a contemporary organizational development priority resulting from incongruent organization-technology interfaces. Technologically induced system failure has been defined as technological iatrogenesis. The chapter offers the Healthcare Iatrogenesis Model as an organizational development strategy to guide the responsible implementation of HIT projects. By recognizing the etiology of incongruent organizational interfaces and anticipating patient safety concerns, leaders can proactively respond to system limitations and identify hidden process instabilities prior to costly and consequential catastrophic events.

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Responding to health information technology reported safety events: Insights from patient safety event reports

Journal of Patient Safety and Risk Management ◽

10.1177/2516043519847330 ◽

2019 ◽

Vol 24 (3) ◽

pp. 118-124 ◽

Cited By ~ 2

Author(s):

Katharine T Adams ◽

Tracy C Kim ◽

Allan Fong ◽

Jessica L Howe ◽

Kathryn M Kellogg ◽

...

Keyword(s):

Information Technology ◽

Patient Safety ◽

Health Information Technology ◽

Health Information ◽

Healthcare Systems ◽

Healthcare Staff ◽

Or Education ◽

Training And Education ◽

Safety Event ◽

Policy Information

Objective We analyzed the described resolutions of patient safety event reports related to health information technology to determine how healthcare systems responded to these events, recognizing that certain types of solutions such as training and education have a limited impact. Methods A large database of over 1.7 million patient safety event reports was filtered to include those identified by the reporter as being related to health information technology. The resolution text was manually reviewed and coded into one or more of four categories: No Resolution, Training/Education, Policy, Information Technology-oriented solution. Results Most events (64%) did not include a resolution. Of those that did, Training/Education was the most commonly reported single or component of a multi-pronged solution (55%), followed by Information Technology (45%). Only 59 events (6% of resolutions) described more than one method of resolution. Conclusion Health information technology-related patient safety event resolutions most often described a solution that suggested additional training or education for healthcare staff, despite the recognized limitations of training and education in resolving these events. Few events suggested multiple resolution methods. Ensuring health information technology-related events are resolved and incorporate effective solutions should be a continued focus area for healthcare systems.

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A comparative review of patient safety initiatives for national health information technology

International Journal of Medical Informatics ◽

10.1016/j.ijmedinf.2012.11.014 ◽

2013 ◽

Vol 82 (5) ◽

pp. e139-e148 ◽

Cited By ~ 31

Author(s):

Farah Magrabi ◽

Jos Aarts ◽

Christian Nohr ◽

Maureen Baker ◽

Stuart Harrison ◽

...

Keyword(s):

Information Technology ◽

Patient Safety ◽

Health Information Technology ◽

Health Information ◽

National Health ◽

Comparative Review

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Effects of health information technology on patient outcomes: a systematic review

Journal of the American Medical Informatics Association ◽

10.1093/jamia/ocv138 ◽

2015 ◽

Vol 23 (5) ◽

pp. 1016-1036 ◽

Cited By ~ 45

Author(s):

Samantha K Brenner ◽

Rainu Kaushal ◽

Zachary Grinspan ◽

Christine Joyce ◽

Inho Kim ◽

...

Keyword(s):

Information Technology ◽

Patient Safety ◽

Health Information Technology ◽

Health Information ◽

Clinical Decision ◽

Cochrane Library ◽

Health It ◽

Term Care ◽

Safety Outcomes

Abstract Objective To systematically review studies assessing the effects of health information technology (health IT) on patient safety outcomes. Materials and Methods The authors employed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement methods. MEDLINE, Cumulative Index to Nursing Allied Health (CINAHL), EMBASE, and Cochrane Library databases, from 2001 to June 2012, were searched. Descriptive and comparative studies were included that involved use of health IT in a clinical setting and measured effects on patient safety outcomes. Results Data on setting, subjects, information technology implemented, and type of patient safety outcomes were all abstracted. The quality of the studies was evaluated by 2 independent reviewers (scored from 0 to 10). A total of 69 studies met inclusion criteria. Quality scores ranged from 1 to 9. There were 25 (36%) studies that found benefit of health IT on direct patient safety outcomes for the primary outcome measured, 43 (62%) studies that either had non-significant or mixed findings, and 1 (1%) study for which health IT had a detrimental effect. Neither the quality of the studies nor the rate of randomized control trials performed changed over time. Most studies that demonstrated a positive benefit of health IT on direct patient safety outcomes were inpatient, single-center, and either cohort or observational trials studying clinical decision support or computerized provider order entry. Discussion and Conclusion Many areas of health IT application remain understudied and the majority of studies have non-significant or mixed findings. Our study suggests that larger, higher quality studies need to be conducted, particularly in the long-term care and ambulatory care settings.

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