Safety Experts Dev Raheja and Maria C. Escano, MD Suggest 7 Solutions for Preventing Errors Associated Electronic Health Records

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I remember a conversation with a retired engineer and friend who was dying of esophageal cancer. He had led a distinguished leadership career in the Navy and later for the US government.  His weight loss and difficulty swallowing had been attributed to a cold  for over a year and the cancer had reached stage IV before an accurate diagnosis and treatment attempts. He wanted to stop treatment and enjoy his remaining time. I don’t think his misdiagnosis had anything to do with Electronic Health Records (EHR), but his illness gained him fast access to the ‘real world’ of health care where details were lost, time was wasted, and errors all to frequent.  We had several wonderful conversations about leadership, death, human limitations, and healthcare systems.  He was convinced that Electronic Health computer, money businessRecords (EHR) would help prevent many errors and wasted costs.  Ed is probably right about the potential of EHRs, yet so far, the statistics indicate that problems persist in their application.

In the May-June 2013 Jounal of System Safety article, “Unintended Safety Problems in Electronic Health Records“, authors Raheja and Escano, describe some of the errors associated with EHRs as well as important ways to prevent them.  Their solutions are excerpted here:

1.  Perform Failure Mode and Effects Analysis (FMEA) on workflow and processes to determine how the unsafe mistakes can be made. This will also help in maintaining accreditation. The Joint Commission requires hospitals to use this method at least once a year.
2. Involve EHR users in developing a checklist of EHR problems found on search engines. Make sure these problems cannot occur before buying the EHR system. If you already have the system, find ways to mitigate these risks with help of the vendor.
3. Perform Preliminary Hazard Analysis (PHA) before buying the EHR system  If the EHR has already been purchased, PHA may still be useful

in upgrading the system. It provides a different view of mishapscenarios. This methodology was covered in a prior article [Ref. 1].
4.  Conduct extensive tests before full implementation to ensure that the health IT system operates as expected.
5.   Provide user training and ongoing support, and educate users about the capabilities and limitations of the system.
6.  Closely monitor the system’s ease of use and promptly address problems that users encounter.
7.  Require reporting of health IT-related events and near misses on incidence reports, with the goal of promoting improvement instead of litigation.
I would also recommend that any feedback loops and reporting be quick and easy to initiate for front-line users.  This would go a long way towards engaging clinicians in collaborative problem-solving.   Issues like waiting for computers to respond or changing passwords in the middle of clinical work and care-giving efforts can give EHRs a bad reputation among users.  (Listening to a patient’s concern about upcoming surgery would be a more valuable use of clinician’s time than sitting in front of a computer screen waiting…)
Ed would be rooting us on towards positive implementation of EHRs in healthcare.

1.  Raheja,D. and Maria C. Escano. “System Safety in Healthcare: Preliminary Hazard Analysis for Minimizing Sentinel, Adverse and Never Events,”
Journal of System Safety, July-August, 2009
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2 Responses to Safety Experts Dev Raheja and Maria C. Escano, MD Suggest 7 Solutions for Preventing Errors Associated Electronic Health Records

  1. Thanks Bob (and Dev and Maria),

    It seems so crazy that we have to wait for something really bad to happen before we address problems. It almost seems like we don’t do anything unless we get caught red-handed. I can’t help but wonder how mistakes with EHRs (and other medical issues) are connected to priorities and values. For instance, if selling a computer system is more important than creating a system that works effectively, then we’ll get systems that are prone to error or non-responsive to users concerns. The other night I was trying to logon, couldn’t, was on hold for 5 min w/ MIS, and then given the option to leave a voice message. Not helpful, I hung up and faxed a message to reorder a medication. In an environment where we are trying to minimize mistakes and wasted time, well, it is frustrating.

    Great quote about time and budget and doing things right, Bob!

    Take care,

  2. Bob Latino says:

    Great points Dev and Maria.

    All of your suggestions promote proaction which as you know, is the central concept of Reliability Engineering. By identifying unacceptable risks ahead of time and taking action to ensure they don’t materialize, we do not have to face (react) to the literal consequences!

    Many of us have been conditioned to be reactive because of our efforts to comply various regulations. Unfortunately, usually very bad consequences have to occur before we are ‘required’ to act via a regulation (i.e. – RCA).

    We must take it upon ourselves to use tools like RCA proactively and find out why our risks are so high in the first place.

    A demonstration of this is the TJC FMEA requirement. While definitely a proactive tool when used properly, this requirement was recently extended from 12 months to 18 months.

    The FMEA standard is LD.04.04.05, element of performance 10.  It reads “at least every 18 months, the hospital selects one high-risk process and conducts a proactive risk assessment.”

    ‘We never seem to have the time and budget to do things right, but we always seem to have the time and budget to do them again!’

What are your thoughts?