PA Patient Safety Report: HIT Contributed to 889 Medication-Error Events in Six Months

March 17, 2017
In the first six months of 2016, Pennsylvania healthcare facilities reported 889 medication-error events that indicated health IT as a contributing factor, according to a report from the Pennsylvania Patient Safety Authority.

In the first six months of 2016, Pennsylvania healthcare facilities reported 889 medication-error events that indicated health IT as a contributing factor, according to a report from the Pennsylvania Patient Safety Authority.

The report noted that the most frequently reported errors included dose omission, wrong dose or overdosage, and extra dose; the most commonly reported systems involved were the computerized prescriber order entry (CPOE) and the pharmacy systems.

“As more healthcare organizations adopted EHRs [electronic health records] and such systems became increasingly interoperable, the Authority observed an increase in reports of HIT-related events, particularly in relationship to medication errors. In response, the Authority implemented additional event reporting questions that would better capture whether HIT was a contributing factor in reported events," explained the Authority's executive director, Regina Hoffman.

The Authority was established under the Medical Care Availability and Reduction of Error (MCARE) Act, as an independent state agency. It is charged with taking steps to reduce and eliminate medical errors.

In its last annual report, the Authority included quantitative data about HIT-related events through 2015, and preliminary data suggested that the predominant number of reports by event type was medication errors. In this in-depth analysis of HIT-related medication errors released this week, the Authority characterized contributing factors of a recent report sample.

Authority analysts found that HIT-related errors occurred during every step of the medication use process and further, a majority of errors reached the patient. High-alert medications (i.e., medications that bear a heightened risk of patient harm if used in error) such as opioids, insulin, and anticoagulants, comprised three of the top five drug categories involved in most events.

"We can examine HIT system failures for both human and system errors. Conducting a root-cause analysis when errors occur, developing a strong culture of safety in which workers feel empowered to report unsafe conditions, and routine HIT system surveillance are just a few approaches to reducing HIT related medication errors. We can also learn from systems that work well," Ellen Deutsch, M.D., medical director for the Authority, said in a statement.

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