A pharmacy technician counts prescription medication at a pharmacy in Edmond, Okla.
In the first six months of 2016, Pennsylvania hospitals reported 889 medication errors or close calls that were attributed, at least in part, to electronic health records and other technology used to monitor and record patients’ treatment.
A majority of the errors pertained to dosages — either missed dosages or an administration of the wrong dose. Of the 889 errors, nearly 70 percent reached the patient. Among those, eight patients were actually harmed, including three involving critical drugs such as insulin, anticoagulants and opioids.
The extent of the injuries was not detailed, although no deaths were recorded.
Those are the stark numbers in a new analysis by the Pennsylvania Patient Safety Authority, an independent state agency that looks at ways to reduce medical errors.
But interpretations of the report’s significance — and specifically the overall benefits and risks of information technology in a hospital setting — cross a wide spectrum.
Do 889 errors signal a major patient safety hazard? Critics believe they could, but probably hundreds of thousands of dosages were administered in Pennsylvania hospitals over that period and the total of eight patients harmed would barely register as a percentage of the total.
On the other hand, errors are notoriously underreported and any software error may mask multiple more errors if system flaws go undetected or unreported.
“This is the classic ‘tip of the iceberg,’” said pharmacist Matthew Grissinger, manager of medication safety analysis for the Patient Safety Authority in Harrisburg and co-author of the analysis with fellow pharmacist Staley Lawes. “We know for a ton of reasons not every error is reported.”
Mr. Grissinger cautioned that the findings are “absolutely not” an indicator that patients are less safe, as hospitals have moved from paper to electronic records incorporating health information technology.
But the authors did conclude that technology meant to improve patient safety “has led to new, often unforeseen types of errors” due to system problems or user mistakes.
Hospitals’ implementation of electronic health records, boosted by financial incentives by the federal government as part of the American Recovery and Reinvestment Act of 2009, address an array of patient safety issues. But some medical professionals remain uneasy with the technology.
Frustration with the technology
In January 2015, 35 physician groups — including the American Medical Association, the American Academy of Family Physicians and the American Society of Anesthesiologists — sent a nine-page letter about electronic health records to the national coordinator for health information at the U.S. Department of Health and Human Services.
Their purpose was to convey their “growing frustration with the way EHRs are performing,” the letter stated.
“Many physicians find these systems cumbersome, do not meet their workflow needs, decrease efficiency, and have limited, if any, interoperability. Most importantly, certified EHR technology can present safety concerns for patients.”
Physician Scot Silverstein, a medical informatics specialist at Drexel University in Philadelphia and vocal critic of electronic health records, calls the software “legible gibberish” better designed for handling warehouse inventory than managing and monitoring patient care in a clinical setting.
“Electronic health records are a massively complex computer application, far too complex than is needed for a clinic taking care of patients,” he said in a phone interview. “EHRs need to be toned down, be less complex, and be used less.”
Opportunities for mistakes are numerous, he said, as a physician may have to scroll through multiple screens, while each screen with a dozen or more columns plus an array of drop down menus. Some systems, he said, allow doctors to keep screens on multiple patients open simultaneously, increasing the chances of a medication mix-up.
“The software needs to be designed better.”
Dr. Silverstein, who says his mother’s death was precipitated by a heart medication mix-up involving her electronic health record, cites federal initiatives giving hospitals financial incentive to implement electronic health systems as pushing the programs without sufficient vetting.
“The thinking was, ‘Computers plus doctors equals better medicine,’ period. But the technology was not and is still not ready for that kind of push.”
Instead, he recommends some combination of paper, with paper imaging capability so records are accessible, and electronic systems. “I don’t think paper should or ever will go away completely,” he said.
A need for better training
Anesthesiologist Andrew Gettinger, acting deputy national coordinator for health information technology in the U.S. Dept. of Health and Human Services, disagrees with Dr. Silverstein.
He identified three key components to a successful electronic health record system — good design and implementation and the users’ good understanding of the system.
“What we find is that many clinicians who complain vociferously about the software and how many clicks it takes, and how user unfriendly it is, have not actually taken the time to understand the system,” he said.
“Quite frankly, doctors are not always the best at signing up for training and taking the training, and some of the training is not always the best.”
He allowed that the usability criticism “is a very legitimate thing to look at” but he defended the federal incentives, saying they defrayed the cost to hospitals while encouraging vendors to develop better systems.
“A system that is well designed and well implemented, and used by the clinician in the way it is designed, actually is pretty strong and pretty good.”
In the patient safety analysis, Mr. Grissinger and his colleague found health information technology errors “occurred during every step of the medication-use process.”
They make several recommendations such as encouraging more reports of errors and near misses, training to ensure new staff are familiar with the technology before using it in patient care, and limiting distractions when performing critical tasks such as ordering medications.
The full report can be viewed online at the authority’s website, www.patientsafetyauthority.org.
The hope, said Mr. Grissinger, is that by tracking errors hospitals can check for possible weak spots as they introduce and monitor electronic health records systems into their hospitals.
“The potential to make this safer for the patient and the provider is absolutely there.”
Steve Twedt; [email protected] or 412-263-1963.
Medication errors in hospitals don’t disappear with new technology
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