9 health IT patient safety issues to know

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The National Quality Forum has released a report detailing recommendations for health IT safety issues. Here are nine core health IT safety elements to know.


1. Clinical decision support. Clinical decision support tools allow providers to analyze patient data and receive guidance on care decisions, but poorly designed tools can have a negative effect on patient safety. The NQF recommends CDS tools take into consideration appropriateness and timing of any alerts.

2. System interoperability. Gaps in communication are a leading cause of patient safety issues. Lack of interoperability can lead to delays in treatment. The NQF recommends identifying ways to assess interoperability and creating measures for known patient safety hazards related to interoperability challenges.

3. Patient identification. Incorrectly identifying a patient can result in wrong-site surgery, medication errors and other patient safety issues. The NQF suggests accountability for patient identification errors be equally shared by all healthcare stakeholders.

4. User-centered design. User-friendly design can result in error reduction and safer, more effective health IT. The NQF outlined a number of potential measures to consider when assessing health IT usability, such as time between patient encounters and chart documentation.

5. System downtime. Patient care and provider workflows become dependent on health IT, such as EHRs, after full implementation. If and when an EHR goes down, patient care can be heavily affected. The NQF stressed the importance of having a plan in place for inevitable downtime, as well as the implementation to measure the number of time downtime procedures are activated.

6. Feedback and information sharing. Vendors and users can identify patient safety issues related to the use of health IT. The NQF recommends healthcare stakeholders freely share information with one another to ensure patient safety issues are not repeated in different settings.

7. Documentation. Complete clinical documentation is essential to quality patient care. The NQF suggests evaluating the timeliness and transmission of clinical data entered into health IT systems.

8. Patient engagement. Health IT increasingly connects patients and their caregivers through tools such as patient portals. The measurement of portal usability should be a focus of health IT patient safety measurement, according to the NQF.

9. Risk management. Vendors and healthcare providers should establish a risk management infrastructure to address and rectify any patient safety issues related to health IT.


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