ED Accreditation Update
New Sentinel Event Alert gives warning: IT implementation has inherent safety risks
While the introduction of new technologies such as computerized physician order entry (CPOE) were lauded by proponents as "silver bullets" that dramatically would improve patient safety, The Joint Commission is warning in a new Sentinel Event Alert that "users must be mindful of the safety risks and preventable adverse events that these implementations can create or perpetuate."
"Technology-related adverse events can be associated with all components of a comprehensive technology system and may involve errors of either commission or omission," the alert says. "These unintended adverse events typically stem from human-machine interfaces or organization/system design." (Editor's note: To download the Alert, go to www.jointcommission.org/SentinelEvents.)
Joan Kolodzik, MS, MD, FACEP. an attending emergency physician at Upper Valley Medical Center, Troy, OH, and director of education/EMS for Premier Health Care Services, Dayton, OH, has first-hand knowledge of the pitfalls that can accompany health information technology (IT) installations. Several years ago, she was working in the ED of a medium-sized rural community hospital that saw about 45,000 patients a year. "The hospital, I'm sure, did a fair amount of research, and it's my understanding they invested about $5 million in the IT system," says Kolodzik.
The hospital purchased the system and implemented it in phases across the hospital, and then came to the ED at the end of August and said it was starting the system on Sept. 1. "They said we'd get five minutes of training when we came in for our first shift using the system, and by the way, CPOE is mandatory," she shares. "We were not allowed to ask the nurses or unit clerks for help, so we kind of looked at each other, and we made the best of it."
The hospital did provide some preliminary training which Kolodzik says was "rudimentary and inadequate." The ED had had no input into the planning process and no input into product selection or in creating the macros of the system. "Sept. 1 was complete gridlock; the computers took us away from the patient's bedside, put us in front of a computer with little training, and it was basically trial and error — in other words, disaster," says Kolodzik.
In addition, she says, the staff ultimately realized that the new system had no ability to generate reports or collect data. "We were forced to use a system that did not meet our needs or allow us to manage data," notes Kolodzik. "At first there was no tracking system, and that was probably the No. 1 piece you need in an ED with an EMR [electronic medical record], so you know who is in the lobby, where the patients are, and where there nurses are."
The awkward implementation also affected the ED staffing situation, says Kolodzik. "We had two very, very experienced ED physicians — with maybe 40 years' experience between them — who were very well liked by the administration and who patients loved; the kind you should clone," she relates. "They went to other sites because they could not make the change." Another physician who worked nights threatened to quit if he was forced to use the system. "It's not easy to find someone works who will work 100% nights, so the hospital made accommodations," says Kolodzik.
You also can hear "war stories" from Timothy Van Fleet, MD, medical director, emergency services, Magee-Womens Hospital of University of Pittsburgh Medical Center (UPMC), assistant professor, Department of Emergency Medicine, University of Pittsburgh School of Medicine, and eRecord liaison, Emergency Resource Management, a UPMC organization that provides ED staffing and support services. "One of the biggest problems we saw with CPOE/EMR rollouts was inadvertently writing an order on the wrong patient," he recalls.
One of the first systems installed, Van Fleet explains, placed a tracking board on every user's computer, and that board could jump into other patients' charts. "It is dynamic; it changes from second to second," he explains. "The doc would have their cursor on a patient's name to click on and go into their chart, but if he or she does it a fraction of a second after the board changes, they may not realize they are in another person's chart, so the doctor would write the order and be on the wrong chart and not realize it."
How can such problems be avoided? "It is a training issue," says Van Fleet. "Your physicians need to double-check before they place the order that they are in the correct patient's chart." With better training, his concerns have lessened, "but this still has the potential to be a big issue," he says.
While the introduction of new technologies such as computerized physician order entry (CPOE) were lauded by proponents as "silver bullets" that dramatically would improve patient safety, The Joint Commission is warning in a new Sentinel Event Alert that "users must be mindful of the safety risks and preventable adverse events that these implementations can create or perpetuate."You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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