The Joint Commission has released a Sentinel Event Alert on safety in information technology (IT). Outpatient surgery might be prone to issues with IT due to systems that don’t allow consistent documentation of notes from the scheduler, part-time staff who work at multiple facilities with different IT systems, and systems that pre-populate fields in the record.
- Before buying, talk to other facilities with that system to ask about their experiences with the vendor.
- Determine whether your system can handle communication issues related to procedures you rarely perform.
- Leaders must be committed to addressing technology issues after the purchase.
IT records must fit the case. Consider this example: A surgeon used one common note for each basic appendectomy procedure in his health information technology (IT) system. He didn’t customize the notes to indicate variances in particular patients. One of his patients had an abscess that could have been explained by these variances, if they had been recorded.
“Unfortunately, the jury did not take kindly to the surgeon’s efficiency in doing his operative note and then having a different ‘memory’ in testimony,” says Jane J. McCaffrey, MHSA, CIC, DASHRM, independent consultant in healthcare risk and compliance, Easley, SC. The jury awarded the patient more than $240,000.
Safe use of health IT is the focus of a new Sentinel Event Alert released by The Joint Commission (TJC). The new alert examines the contributing factors to sentinel events that are health IT-related and includes suggested solutions for healthcare organizations. It builds on another Sentinel Event Alert, Issue 42, issued in 2008, which focused on safely implementing health information and converging technologies.
TJC analyzed 3,375 sentinel events that resulted in permanent patient harm or death from Jan. 1, 2010, to June 30, 2013. Of that group, 120 events were identified as having health IT-related contributing factors. Factors potentially leading to health IT sentinel events involved the following dimensions:
- human-computer interface – ergonomics and usability issues resulting in data-related errors, 33%;
- workflow and communication – issues relating to health IT support of communication and teamwork, 24%;
- clinical content – design or data issues relating to clinical content or decision support, 23%;
- internal organizational policies, procedures, and culture, 6%;
- people – training and failure to follow established processes, 6%;
- hardware and software – software design issues and other hardware/software problems, 6%;
- external factors – vendor and other external issues, 1%;
- system measurement and monitoring, 1%.
Outpatient surgery problems
One of the IT issues found in outpatient surgery programs regards scheduling, particularly in its relationship to wrong-side, wrong-procedure, or wrong-patient surgery, says Gerry Castro, PhD, project director of the Office of Patient Safety at The Joint Commission.
“In particular, the specific sentinel events we’ve encountered occurred where a scheduler was given an order for a specific procedure, and within that electronic interface, there’s a drop-down menu,” Castro says. In some cases, specific details such as laterality or the need to use a different port could not be entered into the system easily. The scheduler might put the information in a note or use some other means to communicate the information, Castro says.
“That particular piece of information doesn’t always make itself available to the person doing the procedure,” he says. One of the problems is that not all parts of a patient’s medical record are available to all persons who access the record, Castro says.
Data integrity was the No. 2 patient safety issue on the list recently released by ECRI Institute. Specifically, the Institute mentions incorrect or missing data in EHRs and other health IT systems. (For more information on ECRI Institute’s list, see story in this month’s main issue of Same-Day Surgery.)
Another issue in outpatient surgery is that the heavy use of part-time staff means many staff members are working with multiple IT systems.
Michael W. Jopling, MD, executive vice president of Columbus, OH-based Accel Anesthesia, a consulting firm that is developing its own anesthesia record-keeping system, says, “Many people can become very skilled at a single system, but it’s very difficult to work between multiple centers. Or they may be working at two hospitals.”
Working with different systems is a distraction, Jopling says. For example, a provider has to stop and figure out where he or she should enter medications or vital signs.
“Anything detracting you from the patient to work on a piece of technology is not helpful,” Jopling says.
The solution is to become well-versed enough in a particular IT system so you’re not distracted, he says.
Another issue is that prepopulated systems can cause errors. Because of the fast-paced environment in outpatient surgery, some facilities are tempted to “cut corners” by using prepopulated forms with which you can hit one button and populate multiple areas, Jopling says.
“A lawyer would blow a hole in that method of documentation," he says.
Also, Jopling warns that people who are technology-averse are drawn to working in ambulatory surgery centers because many still use paper records. However, he describes the creep of electronic medical records (EMRs) into outpatient surgery centers as “inevitable.”
Focus on these areas, say sources interviewed by Same-Day Surgery:
- Carefully research potential systems before buying.
When looking for an IT system, talk to healthcare providers who already have those systems in place, Castro advises.
Be sure to ask about their experience with the vendor, he says. “Vendor support has been shown to play a tremendous role in success of any implementation,” Castro says.
Outpatient surgery providers should adapt IT to their processes, he says, and you’ll need vendor support. “You don’t want technology to change your processes. You want it to facilitate your process,” Castro says.
- Assess your system’s capabilities for potential communication problems.
Assess your current system for its ability to handle the types of procedures you perform, Castro says.
Go beyond the procedures you perform on a daily basis to examine how your system handles rare procedures, he says. Answer these questions, Castro advises: Do you have a set process for communicating? Are there specific details that need to be communicated to the procedurist, and is there a set process for doing that? Can that person ask a question? Can they check with somebody? Is there a way to double check the information?
This examination can be part of a Failure Mode and Effects Analysis (FMEA), Castro says. Also, providers can use the SAFER Guides for EHRs checklists (Web: http://healthit.gov/safer). The Alert includes some recommendations adapted from the High Priority SAFER Guides. Those recommendations include:
- Make health IT hardware and software safe and free from malfunctions. “Before going live and as appropriate after implementation, conduct extensive testing, including downtime drills and involving frontline staff end-users, on hardware and software and system-to-system interfaces to ensure data are not lost or incorrectly entered, displayed, or transmitted,” the Alert says. “Assign responsibility for this testing, as well as for ongoing monitoring and maintenance of the system’s performance and safety.”
- Make the use of health IT by clinicians, staff, and patients safe and appropriate. “Configure systems to allow clinicians to easily correct accidental clicks, typos, or drop-down choices,” the Alert says.
The key point is accuracy of your communication, Castro says. “If you think about it, these problems have occurred even before EMRs,” he says. “The accuracy of communicating from point A to B has been in existence since we started this whole business. Technology can help the problem or hinder the problem.”
- Understand that the process doesn’t end with the purchase.
The role of leadership is essential, Castro says. Sometimes leaders approve the purchase of a health IT system and think that step is the end, when it’s just the beginning, he says.
Sometimes the purchased technology doesn’t work correctly, and leaders take the stance, “We paid for it. You have to figure it out.”
“Leadership has to understand: It’s an ongoing process of optimizing technology,” Castro says. “It’s not the only commitment you have to continually optimize the technology for the processes.”
- Sentinel Event Alerts. Web: http://www.jointcommission.org/sentinel_event.aspx.
- The Joint Commission offers a free CE course Investigating and Preventing Health Information Technology-Related Patient Safety Events. For more information, visit TJC's Safe Health IT Saves Lives web page. Web: http://www.jointcommission.org/safe_health_it.aspx.
- TJC offers an infographic about IT issues. Web: http://bit.ly/19J9Wq4.
- Michael W. Jopling, MD, Executive Vice President, Accel Anesthesia, Columbus, OH. Phone: (800) 794-1965. Email: firstname.lastname@example.org.