HIT-related patient safety incidents

The Commission asked the Australian Institute of Health Innovation at Macquarie University to perform a literature review and environmental scan on approaches to the review and investigation of Health IT-related patient safety incidents to:

• Identify appropriate methods for monitoring hazards affecting HIT systems 
• Investigate incidents resulting from the use of these systems.

A Literature review and environmental scan on approaches to the review and investigation of Health IT-related patient safety incidents published in 2017 found that the requirements for HIT safety systems:

• Are similar to those that apply to existing patient safety systems
• Should include the ability to identify hazards ahead of time and permit review of incidents after the event
• Should also provide information about the prevalence of incident reporting and management systems
• Should allow the opportunity to classify and report on incidents to ensure a continuous open loop of feedback and improvement.

The review noted that numerous methodologies exist and that no single method was appropriate to detect, investigate and classify all HIT incidents. Successful HIT safety systems need to have in place a multidisciplinary team with appropriate skill sets from a clinical, health informatics and system safety perspectives and use a tailored approach to investigate HIT patient safety incidents.

As HIT systems are being implemented in most Australian states and territories, and some private hospitals, HIT-related safety risks continue to be unintended consequences from their implementation. Complex and difficult issues, to which implementation teams must be alert, are arising, and little is known about the types of errors that may be associated with:

• EMM-related work practice changes
• Clinicians working across multiple sites and settings, and remote ordering
• Hybrid environments in which EMM and hard-copy documentation for prescribing and administration of medicines, are both used
• Multiple EMM systems, such as separate ICU or oncology systems
• Multiple patient EMM records being open at the one time
• Selection errors associated with use of ‘drop-down’ medicine lists when prescribing
• Dosing errors associated with on-screen presentation of medicines information
• Decision support information not being used, not readily accessible for use, or not considered relevant (interaction alerts) by clinicians
• Planned and unplanned downtime.

In 2019, the Commission repeated the literature review an Update on approaches to the review and investigation of health IT-related patient safety incidents.

Key findings:

• Despite a marked number of reported investigations into health IT-related patient safety incidents, no notable developments for using existing taxonomies to classify these events were found
• The literature did not contain examples of data breach incidents relating specifically to EMR design, build and use being routinely recorded and reported.