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Penn. study shows patients at risk from EHR-related data errors

By Jennifer Bresnick

Reports about electronic health records usually focus on adoption rates, technological advances, and patient benefits.  While the rapid proliferation of EHR technology is generally thought to be a good thing, few organizations responsible for producing statistics on EHR usage collect data on patient safety and adverse events linked to the misuse of EHR information.  Pennsylvania’s Patient Safety Authority is the only state agency collecting a significant amount of EHR patient safety data.  In one of the largest studies to date, they analyzed 3,099 EHR-related events, finding that 10% of events led to “unsafe conditions”, while 16 events caused actual harm to a patient.

Bill Marella, MBA, program director for the Pennsylvania Patient Safety Authority, said that “data entry errors not caught by the system, data entered into wrong fields, misreading or misinterpreting displayed information, and providers incorrectly accepting default values when entering orders” were among the problems categorized as an “event” in the study.  The fifteen events that caused temporary harm to patients involved a practitioner entering the wrong medication, ignoring a documented allergy, failing to enter lab tests, and failure to document a procedure or condition.

In one example, a patient with a documented penicillin allergy was administered ampicillin and went into shock, possibly due to anaphylaxis.  The allergy was “written on some order sheets and “soft” coded into Meditech but never linked to the pharmacy drug dictionary,”  according to authors of the study.  While no patients died due to these errors, and only one additional patient suffered serious harm from an EHR-related mistake, it’s clear that carelessness when entering or reading EHR data is a cause for concern.

“With the rapid adoption of electronic health records in the healthcare industry, there is growing concern that safety is not at the top of the agenda,” Marella added. “The Authority study gives not only Pennsylvania healthcare facilities, but all healthcare facilities implementing this technology, a glance at the potential problems they should anticipate and monitor after implementation.”

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