Incident Reporting and Hazard Control. James M. Walker, MD, FACP Chief Health Information Officer

Transcription

1 Incident Reporting and Control James M. Walker, MD, FACP Chief Health Information Officer 1

2 Reporting HIT-related Incidents? Care Process Compromise? Identifiable Harm? Harm Incident Reporting Adverse Effect Near Miss 2

3 Control analysis is accident analysis before the accident happens. Nancy Leveson 3

4 The Contribution of HIT-related s to Harm Error in HIT design or implementation HIT-Related Interaction between HIT and other healthcare systems. Identified? Resolved? Adverse Effect Un-Forced HIT-use Error HIT-related Forced HITuse Error Care Process Compromise? Identifiable Harm? Harm Adverse Effect Near Miss 4

5 Control Error in HIT design or implementation HIT-Related Interaction between HIT and other healthcare systems. Identified? Control Resolved? Adverse Effect Un-Forced HIT-use Error HIT-related Forced HITuse Error Care Process Compromise? Identifiable Harm? Harm Adverse Effect Near Miss 5

6 Feeding Back Incident Reports into Control Error in HIT design or implementation HIT-Related Interaction between HIT and other healthcare systems. Safety incident reports Identified? Resolved? Adverse Effect Un-Forced HIT-use Error HIT-related Forced HITuse Error Care Process Compromise? Identifiable Harm? Harm Adverse Effect Near Miss 6

7 Barriers to Control Limited uptake of human-factors engineering and safety engineering CDOs, HIT developers, regulators, and researchers Retrospective focus on safety incidents to the exclusion of proactive hazard control Absence of a standard language for HIT hazards Fear of reputational and medicolegal injury CDOs HIT Developers (including vendors) HIT Supporters 7

8 Report Recipients s, care-process compromise without and with patient harm should be reported and shared at the following levels: CDO - fully identified. Developer (vendor) communities patient and CDO deidentified. Researchers, regulators, and policy makers patient, CDO, and developer (vendor) de-identified. 8

9 Health IT Support for Reporting HIT-related s a. Ross Koppel s Report Problem button b. David Classen s automated care-process compromise identification tool 9

10 Mandatory Reporting: HIT Developers, Implementers, and Users a. Feasible - De-identified reporting of hazards b. Possibly Feasible -De-identified reporting of care-process compromise without patient harm c. The HIT-related hazards identified in analyses of patient harm should be included in the HIT Manager reporting system. 10

11 Template The IOM committee on patient safety and health IT will be holding its first meeting on December in Washington DC (exact place TBD). We are currently planning an open workshop session on December 14 to receive public statements about the committee's task (see below). I am writing to ask if you would be interested and available to address the committee in the afternoon of the 14th to help us better understand reporting of patient safety events related to health IT from the provider's perspective. Specifically, we're interested in the following: Identify challenges to improve reporting of patient safety incidents (e.g., lack of common formats, liability, privacy). What events should be reported that can be rolled up to a national level? Are they defined and ready for inclusion in the meaningful use criteria? How can health IT help make reporting more effective? Is mandatory or voluntary reporting needed? At what level? 11

12 Statement of Task An ad hoc committee will review the available evidence and the experience from the field on how the use of health information technology (HIT) affects the safety of patient care and will make recommendations to concerning how public and private actors can maximize the safety of HIT-assisted health care services. The committee will produce a report that will be both comprehensive and specific in terms of recommended options and opportunities for public and private interventions that may improve the safety of care that incorporates the use EHRs and other forms of HIT. "HIT-assisted care" means health care and services that incorporate and take advantage of health information technologies and health information exchange for the purpose of improving the processes and outcomes of health care services. HIT-assisted care includes care supported by and involving: EHRs, clinical decision support, computerized provider order entry, health information exchange, patient engagement technologies, and other health information technology used in clinical care. 12

13 Statement of Task The committee will: * Summarize existing knowledge of the effects of HIT on patient safety; * Make recommendations to HHS regarding specific actions that Federal agencies should take to maximize the safety of HIT-assisted care; and * Make recommendations concerning how private actors can promote the safety of HIT-assisted care, and how the federal government can assist private actors in this regard. 13