While frontline staff report IT-related safety events, health systems often focus on staff training to resolve the issues rather than address the underlying technology problems, according to a recent study.
Plenty of studies have pointed to the link between the usability of health IT systems—particularly electronic health records (EHRs)—and patient safety. But when researchers from MedStar Health's National Center for Human Factors in Healthcare analyzed more than 2,600 patient safety event reports related to health IT, they found almost two-thirds of those reports (64%) did not describe any actions taken to resolve the issue, according to the study published in the Journal of Patient Safety and Risk Management.
In most cases, when the issue was resolved the health systems focused on additional training and education for healthcare staff rather than engaging IT support to address the technology glitches. Only 45% of reports cited an IT-oriented solution to the issues, and 7% addressed the patient safety issue by establishing a new policy.
Education and training have a limited impact in resolving these events, the researchers noted.
“Although these events had been self-identified as being health IT-related, IT interventions were less frequently targeted as the method of resolution, particularly for events that reached the patient,” the researchers said.
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Forty-four percent of events did not reach the patient, while 52% did reach the patient but did not cause harm, and 4% of events actually resulted in patient harm, according to the study,
Frontline staff typically use patient safety event reporting systems to report a range of adverse events experienced in their day-to-day work, from events that are deemed “near misses” to serious safety events that lead to patient harm. Another staff member, often a patient safety officer or a local clinical leader, reviews the report and enters the resolution, according to the study researchers.
While acknowledging that health IT-related safety events are often underreported, the MedStar researchers were interested in evaluating how healthcare systems are responding to health IT-related safety issues by analyzing events reported to the Pennsylvania Patient Safety Authority’s patient safety reporting system as well as reports from a large multihospital academic medical center between 2009 and 2016.
The study results suggest organizations are not focused on long-term fixes when issues arise.
As an example, one event described a failure in transferring results of an imaging study from the radiology IT system to the EHR system. To address the issue, the radiology technician was reeducated on methods to confirm the information transfer, according to the study.
“A more encompassing approach to resolving the issue could include confirming appropriate software interoperability and introducing potential system improvements, such as automatic system notifications,” the researchers wrote.
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While education and policy reinforcement are commonly proposed solutions to patient safety events, these are person-focused solutions and are unlikely to lead to effective and sustainable change. Broader system design and organizational improvements are more likely to improve safety, according to the researchers.
The researchers also noted an interesting trend where health systems were more likely to engage their in-house IT teams or a vendor's IT support for a patient safety event that did not reach the patient. Safety events that had the most impact on patients more often were resolved with a focus on training or education.
“This could suggest that when safety events reach the patient or result in patient harm there is a tendency to look for immediate resolution by focusing on person-centric solutions rather than waiting for likely more effective IT solutions that often take more time and resources to implement,” the researchers wrote.
"For the subset of health IT-related events that did describe a resolution requiring health IT support or intervention, only about one-third stated that the event was successfully addressed," the study authors wrote.
The researchers suggest further study into other avenues for addressing health IT-related challenges such as utilizing help desk tickets as a data source, which could provide more insight into how these events are addressed and offer ways to improve the efficacy of solutions.
The analysis, the researchers wrote, highlights a need to ensure that these events are being resolved and that the implemented resolutions are robust and effective over the long term.