Discharge instructions for a child’s insulin dose were correctly entered into the electronic health record (EHR), but when the mother received the printed instructions there was a decimal point error resulting in a 10-times dosing error. This error was fortunately noticed by the bedside nurse and corrected manually. I reported this near-miss to the EHR vendor and they corrected the technical problem. However, when I asked vendor representatives whether or not this problem was being corrected with other physician clients across the country, they informed me that no other client had reported such a problem.
This is analogous to a situation where an airbag explodes and sends shrapnel into your face. You might ask the automaker whether this is a problem with their other vehicles. They might tell you that they are not aware of others having the same problem. However, in the transportation industry they are required to report safety incidents and near-misses. These reports are collected, aggregated and analyzed by the National Transportation Safety Board (NTSB). If NTSB notices a trend in airbag-induced shrapnel injuries, they will initiate an investigation. When NTSB discovers a problem with a specific airbag that is used across multiple types of automobiles, not just the type you purchased in your own state, then they are authorized by Congress to make safety recommendations to help ensure the risk is appropriately managed across the industry.
This insulin dosing incident is one of many health IT-related patient safety risks I have encountered and resolved in collaboration with an EHR vendor. When my experience is extrapolated to the experiences of all physicians and EHR vendors, the scope of health IT-related patient safety risks can be seen as immense. But unlike the safety of interstate commerce produced by the auto industry that is overseen by the NTSB, the safety of interstate commerce produced by EHR vendors has no cohesive oversight mechanism.
The lack of oversight for health IT-related patient safety incidents and near-misses creates a hazardous patient care environment that I believe is urgent for Congress to address. The threat is increasing because the Meaningful Use Program (MU) has led to an exponential increase in the use of EHRs and other technology. As a result, physicians are assuming a higher level of risk and accountability for computer programs, networks and infrastructures that are increasingly used as tools to generate patient care actions and facilitate medical decisions. Although health IT-related patient safety risks would best managed through a shared accountability between physicians and EHR vendors, the vendors are not currently held accountable for patient safety. Furthermore, the aggressive MU timelines have required EHR vendors to make rapid changes to EHRs without sufficient time to align changes with efficient physician workflows or to improve the flow of data between systems. As a result, EHRs are increasingly plagued by poor usability problems and lack of interoperability between EHR systems--both of which are patient safety risks that physicians commonly encounter.
So it is time to urge Congress to create a National Health IT Safety Center that can implement an effective EHR safety program designed to reduce EHR-related patient safety risks. Within this concept EHR vendors could be required to report patient safety incidents and near-misses to the Health IT Safety Center similar to how transportation safety incidents must be reported to the National Transportation Safety Board. The Health IT Safety Center could collect, aggregate and analyze reported data. It could have power to investigate incidents involving patient harm and require EHR vendors to make appropriate changes. It could monitor near-misses to identify trends and risks. It could coordinate with other agencies to develop and broadly disseminate educational information and tools that mitigate identified patient safety risks related to technology use.
I also envision that this resolution would lead to an entity that has the authority and influence to drive improvements in EHR usability and
interoperability, which are the two most significant impediments to effective and meaningful use of electronic medical records.