Better Tech No Guarantee Of Better Care

Reports highlight significant patient safety risks posed by advances in health IT.

Greater use of health information technology by hospitals and doctors often is touted as the key to improving the quality and safety of patient care. But two new reports highlight the significant risk to patient safety posed by health IT when not designed effectively or used properly by caregivers.

For employers who ultimately pay higher health insurance premiums to pay for the new information technologies, the reports suggests that they may be paying a little extra to fix the unintended clinical problems that the new technologies may be creating.

The first report, Preventing Medication Errors in Hospitals, is based on a survey of 1,750 hospitals by The Leapfrog Group, the Washington-based employer coalition focused on the quality and safety of care. Some 96 percent of the hospitals used a computerized physician order entry (CPOE) system in 2015 to order medications prescribed to hospitalized patients. That adoption rate is up significantly from 33 percent in 2010.

Automated CPOE systems do such things as verify prescriptions, match drug orders to patients, check dosages against diagnoses, identify potential contraindications with other medications, flag potential medication errors and note patients’ allergies to certain medications.

An analysis of the data collected from the surveyed hospitals on how well their CPOE systems performed uncovered some serious problems. It found that in aggregate the hospitals’ CPOE systems failed to alert staff to 39 percent of potentially harmful drug orders and to 13 percent of potentially fatal drug orders.

“Hospitals spend millions of dollars to implement CPOE systems, but our results clearly show that many hospitals’ systems are not operating as well as they should, putting patients’ lives at risk,” Leapfrog President and CEO Leah Binder said in a statement.

The second report is from the ECRI Institute, the independent healthcare testing and review organization based in Plymouth Meeting, Pennsylvania. In its Top 10 Patient Safety Concerns for Healthcare Organizations for 2016, ECRI put health IT at the top of its list. Specifically, ECRI named health IT configurations that don’t match or support clinical care workflows as the biggest risk to patient safety at healthcare facilities.

“When health IT configuration and workflow clash, communication suffers,” ECRI said in its report. “For example, not having up-to-date information about a patient’s allergies, weight, medications, tests, treatments or code status can lead to errors or delays in care.”

Medication errors also made ECRI’s list at No. 7 with mixing up patients’ weight in pounds and kilograms to determine proper drug dosages as the culprit—an error that CPOE systems are supposed to catch.

Medication errors are up in Minnesota, although they represent a small percentage of the adverse health events reported to the Minnesota Department of Health by hospitals and surgery centers.

In 2015, hospitals and surgery centers reported 316 adverse health events to the state, according to the department’s latest annual report. Of those incidents, 14, or less than 5 percent, were due to medication errors.

However, the 14 medication errors were the highest number of annual drug mistakes reported to the state since the reporting of serious patient safety accidents became mandatory in 2004. It’s double the seven drug errors reported in 2014 and one more than the previous record of 13 recorded in 2010. All 14 drug errors in 2015 resulted in serious injury to or death of the patient.

Minnesota was one of 11 states with the highest percentage of CPOE adoption by hospitals in 2015, according to The Leapfrog Group report.