Preventing EHR-Related Medical Errors at Your Health Center

Unless you’ve been hiding under a rock for the past week (and if you have been, no judgment here), you know that an Ebola-infected patient is currently being treated in a Dallas, Texas hospital. (Update: Patient died on Wednesday, October 8th.)

Last Thursday, news was released that the patient was not diagnosed correctly during his initial contact with Texas Health Presbyterian Hospital because of a workflow flaw in the health system’s EHR. The flaw involved the travel history section of the patient record. The patient had mentioned that he had been in Liberia, but this information was only viewable in the section that the nurses accessed, not the physician-accessible section of the record.

The hospital reported that this lack of information led them to not place the patient under immediate quarantine - The patient was later appropriately diagnosed and quarantined after he returned to the hospital three days later with worsening symptoms. As a result of this delayed diagnosis, health officials estimated that 50 additional people were potentially exposed to the Ebola virus, 10 of them now considered at high risk for infection. 

Texas Health Resources, the hospital’s parent company, has since changed its story, saying that there was no workflow flaw, and that the physicians did indeed have access to the travel history of the patient.

Although we may never know what actually occurred, this incident heightens our existing concerns that poorly designed EHR workflows can lead to potentially tragic results. In a case such as this where infectious disease is involved, the effects may reach beyond the patient and family members and strike the community at large.

The takeaway message is this: EHRs, even with their many potential benefits to patients and healthcare providers, must not be excused from thorough evaluation as part of an organization-wide workflow analysis that should take place in every health center. 

In the Health Information Technology Patient Safety Action & Surveillance Plan, released by the Office of the National Coordinator for Health Information Technology (ONC) in July 2013, the importance of risk-identification and management in health IT systems such as EHRs was heavily stressed:

While health IT presents many new opportunities to improve patient care and safety, it can also create new potential hazards. For example, poor user interface design or unclear information displays can contribute to clinician errors. Health IT can only fulfill its enormous potential to improve patient safety if the risks associated with its use are identified, if there is a coordinated effort to mitigate those risks, and if it is used to make care safer. (Source: http://www.healthit.gov/sites/default/files/safety_plan_master.pdf)

As a result of the recommendations set forth in the Health Information Technology Patient Safety Action & Surveillance Plan, the ONC developed the SAFER Guides. These guides are “designed to help healthcare organizations conduct self-assessments to optimize the safety and safe use of EHRs. [They] were developed based on the best evidence available including a literature review, expert opinion, and field testing at a wide range of healthcare organizations, from small ambulatory practices to large health systems.”  (Source: http://www.healthit.gov/policy-researchers-implementers/health-it-and-safety)

You can find the SAFER Guides, as well as links to a number of other helpful resources like Workflow Assessment Toolkits and a Guide to Reducing Unintended Consequences of EHRs on the HealthIT.gov website.

If you feel your health center might need additional help with evaluating your EHR workflow or other organizational processes, you can contact FQHC Germane for a consultation.

Sources: 

http://www.beckershospitalreview.com/healthcare-information-technology/ehr-workflow-flaw-caused-texas-health-dallas-to-initially-miss-ebola-diagnosis.html

http://www.modernhealthcare.com/article/20141003/NEWS/310039978?AllowView=VDl3UXk1SzVDdmVCbkJiYkY0M3hla09wakVVZERlND0=&utm_source=link-20141003-NEWS-310039978&utm_medium=email&utm_campaign=hits&utm_name=top

http://www.healthit.gov/sites/default/files/safety_plan_master.pdf

http://www.healthit.gov/policy-researchers-implementers/health-it-and-safety


Jennifer Garces de Marcilla is a Project Manager at FQHC Germane, a health care consulting firm specializing in the needs of established, new and potential Federally Qualified Health Centers (FQHCs).

Read more about Jennifer here.

To contact Jennifer, email her at jweinman@fqhc.org.