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

2019 ◽  
Vol 24 (3) ◽  
pp. 118-124 ◽  
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.

scholarly journals Using Active Learning to Identify Health Information Technology Related Patient Safety Events

2017 ◽  
Vol 26 (01) ◽  
pp. 35-46 ◽  
Author(s):  
Allan Fong ◽  
Jessica Howe ◽  
Katharine Adams ◽  
Raj Ratwani
Keyword(s):  
Information Technology ◽  
Patient Safety ◽  
Active Learning ◽  
Health Information Technology ◽  
Health Information ◽  
Sampling Strategy ◽  
Safety Hazards ◽  
Learning Techniques ◽  
Safety Event ◽  
Review Reports

SummaryThe widespread adoption of health information technology (HIT) has led to new patient safety hazards that are often difficult to identify. Patient safety event reports, which are self-reported descriptions of safety hazards, provide one view of potential HIT-related safety events. However, identifying HIT-related reports can be challenging as they are often categorized under other more predominate clinical categories. This challenge of identifying HIT-related reports is exacerbated by the increasing number and complexity of reports which pose challenges to human annotators that must manually review reports. In this paper, we apply active learning techniques to support classification of patient safety event reports as HIT-related. We evaluated different strategies and demonstrated a 30% increase in average precision of a confirmatory sampling strategy over a baseline no active learning approach after 10 learning iterations.

scholarly journals Identifying health information technology related safety event reports from patient safety event report databases

2018 ◽  
Vol 86 ◽  
pp. 135-142 ◽  
Author(s):  
Allan Fong ◽  
Katharine T. Adams ◽  
Michael J. Gaunt ◽  
Jessica L. Howe ◽  
Kathryn M. Kellogg ◽  
...  
Keyword(s):  
Information Technology ◽  
Patient Safety ◽  
Health Information Technology ◽  
Health Information ◽  
Event Report ◽  
Safety Event

scholarly journals Development of a Taxonomy for Medication-Related Patient Safety Events Related to Health Information Technology in Pediatrics

2020 ◽  
Vol 11 (05) ◽  
pp. 714-724
Author(s):  
Kirk D. Wyatt ◽  
Tyler J. Benning ◽  
Timothy I. Morgenthaler ◽  
Grace M. Arteaga
Keyword(s):  
Information Technology ◽  
Patient Safety ◽  
Health Information Technology ◽  
Health Information ◽  
Improve Patient Safety ◽  
Help Desk ◽  
Safety Improvement ◽  
Safety Event ◽  
Improve Patient ◽  
Medication Related Events

Abstract Background Although electronic health records (EHRs) are designed to improve patient safety, they have been associated with serious patient harm. An agreed-upon and standard taxonomy for classifying health information technology (HIT) related patient safety events does not exist. Objectives We aimed to develop and evaluate a taxonomy for medication-related patient safety events associated with HIT and validate it using a set of events involving pediatric patients. Methods We performed a literature search to identify existing classifications for HIT-related safety events, which were assessed using real-world pediatric medication-related patient safety events extracted from two sources: patient safety event reporting system (ERS) reports and information technology help desk (HD) tickets. A team of clinical and patient safety experts used iterative tests of change and consensus building to converge on a single taxonomy. The final devised taxonomy was applied to pediatric medication-related events assess its characteristics, including interrater reliability and agreement. Results Literature review identified four existing classifications for HIT-related patient safety events, and one was iteratively adapted to converge on a singular taxonomy. Safety events relating to usability accounted for a greater proportion of ERS reports, compared with HD tickets (37 vs. 20%, p = 0.022). Conversely, events pertaining to incorrect configuration accounted for a greater proportion of HD tickets, compared with ERS reports (63 vs. 8%, p < 0.01). Interrater agreement (%) and reliability (kappa) were 87.8% and 0.688 for ERS reports and 73.6% and 0.556 for HD tickets, respectively. Discussion A standardized taxonomy for medication-related patient safety events related to HIT is presented. The taxonomy was validated using pediatric events. Further evaluation can assess whether the taxonomy is suitable for nonmedication-related events and those occurring in other patient populations. Conclusion Wider application of standardized taxonomies will allow for peer benchmarking and facilitate collaborative interinstitutional patient safety improvement efforts.

scholarly journals Identifying Safety Hazards Associated With Intravenous Vancomycin Through the Analysis of Patient Safety Event Reports

2020 ◽  
pp. 31-47
Author(s):  
Adam Krukas ◽  
Ella Franklin ◽  
Chris Bonk ◽  
Jessica Howe ◽  
Ram Dixit ◽  
...  
Keyword(s):  
Information Technology ◽  
Patient Safety ◽  
Health Information Technology ◽  
Health Information ◽  
Assessment Tool ◽  
Improve Patient Safety ◽  
Close Monitoring ◽  
Safety Hazards ◽  
Safety Issues ◽  
Safety Event

Intravenous (IV) vancomycin is one of the most commonly used antibiotics in U.S. hospitals. There are several complexities associated with IV vancomycin use, including the need to have an accurate patient weight for dosing, to provide close monitoring to ensure appropriate drug levels, to monitor renal function, and to continue delivery of the medication at prescribed intervals. There are numerous healthcare system factors, including workflow processes, policies, health information technology, and clinical knowledge that impact the safe use of IV vancomycin. Past literature has identified several safety hazards associated with IV vancomycin use and there are some proposed solutions. Despite this literature, IV vancomycin–related safety issues persist. We analyzed patient safety event reports describing IV vancomycin–related issues in order to identify where in the medication process these issues were appearing, the type of medication error associated with each report, and general contributing factor themes. Our results demonstrate that recent safety reports are aligned with the issues already identified in the literature, suggesting that improvements discussed in the literature have not translated to clinical practice. Based on our analysis and current literature, we have developed a shareable infographic to improve clinician awareness of the complications and safety hazards associated with IV vancomycin and a self-assessment tool to support identification of opportunities to improve patient safety during IV vancomycin therapy. We also recommend development of clear guidelines to optimize health information technology systems to better support safe IV vancomycin use.

scholarly journals 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

2016 ◽  
Vol 25 (01) ◽  
pp. 70-72 ◽  
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.

Health Information Technology

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.

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

2013 ◽  
Vol 82 (5) ◽  
pp. e139-e148 ◽  
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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