How to eliminate 'never events': 5 takeaways about EHR design, use error and patient harm

Is it possible to mitigate patient harm by addressing the design flaws that cause user error in EHRs? A new document published by the National Institute of Standards and Technology offers standards and a framework to do just that.

The report offers guidelines focused on eliminating "never events" and other types of negative patient outcomes through tailored EHR design and implementation elements. The findings are based on five methods of data collection, including online surveys, site observations, follow-up interviews with users, usability testing of five different EHRs and expert reviews of those same EHRs.

Here are five takeaways from the report.

1. While many studies have demonstrated the implementation of health may improve healthcare outcomes and reduce patient mortality, some have shown the technology can contribute to negative outcomes, such as medication overdoses.

2. Researchers determined three critical areas of use risk: identification of information, consistency of information and integrity of information. Across these risks areas several major possibilities for risks related to patient safety: the occurrence of unintended actions, the likelihood of use errors and the high level of user frustration.

3. Real-world examples of these risk cases include how transition periods for patients moving between care settings often result in discrepancies in medication lists, the difficulty of completing tasks such as creating an accurate patient summary and how a lack of user-friendliness in EHRs can result in patient safety and hospital liability concerns.

4. The researchers conclude inadequate documentation, inaccurate information, irretrievable information and the lack of availability of clinically relevant information are EHR qualities that contribute to patient harm.

5. They included the following three recommendations to create a better-designed EHR.
• Consistently displaying information critical to patient identification in a static portion of the record to avoid wrong patient errors
• Providing cues to reduce risks of entering information and writing orders in the wrong patient's chart
• Supporting efficient and easy identification of inaccurate, outdated or inappropriate items in simple lists of grouped information

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