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● Strategic Directives Bringing together PSOs

and health IT A perfect collaboration for quality patient care.

By Stephanie Zaremba I

n healthcare, patient safety events are tough to talk about. Healthcare providers take their responsibility to patients seriously; they spend years training in the pursuit of healing and take an oath to do no harm.

When a patient safety event occurs, something (or many things) has gone wrong, and frankly no one likes to talk about the mistakes made. Medical malpractice litigation is notoriously high stakes and, sometimes, vicious. It is no wonder that in healthcare settings across the country, risk managers advise providers to say and document nothing following a safety event. In 1999, the Institute of Medicine published a report

called “To Err is Human,” which estimated that as many as 98,000 patients die every year as a result of avoidable medical error. T e report also detailed the “shame and blame” culture in healthcare that leads providers to cover up safety issues. Congress recognized this issue and in 2005 enacted the

Patient Safety and Quality Improvement Act to encourage a culture of safety and continual learning and improvement among healthcare providers. T e law authorized the creation of patient safety organizations (PSOs), which serve as safe spaces for the reporting, investigation, analysis, resolution and mitigation of patient safety issues. All information and discussions that happen within the patient safety evalua- tion system are confi dential and privileged, meaning that they cannot be disclosed and cannot be discovered as part of litigation. In return for these protections, PSOs must publish im-

portant learnings from their data, which is aggregated and de-identifi ed. T e result has been a new wave of benchmarks, trends and best practices released to healthcare providers across the country. T is is the real promise of PSO reporting: By shifting the connotation of disclosure from something shameful to something with real utility, the healthcare community can incentivize honest discussion about the causes of safety events and then learn and improve from those discussions.

16 June 2014 T ere are now approximately 80 PSOs across the coun-

try, and they have become a fairly well established piece of patient safety in most health systems. Healthcare providers and administrators are accustomed to handling all sorts of actual or potential safety events, including those that involve a drug or medical device. What happens, though, when we introduce a new and pervasive technology to the delivery of care? T at is exactly the crossroads at which healthcare fi nds itself with the use of health IT. T anks in part to the Mean- ingful Use incentive program, adoption of electronic health records (EHRs) and other health IT has accelerated at a staggering pace. We are not far from the day where every instance of patient care involves the use of an EHR, yet we are only starting to consider the impact of these technolo- gies on patient safety. Certainly, health IT has the potential to greatly improve patient safety by automating human error-prone tasks, providing alerts or eliminating illegible handwriting, for example. But the introduction of new systems and tech- nologies into care delivery always introduces new risks, and health IT is no exception. T e limited existing research shows that safety issues can occur in the design, develop- ment, implementation, customization and use of health IT. A comprehensive approach to patient safety learning and reporting is essential to ensure the safe use of health IT in the future. It is ironic, then, that PSO reporting systems can actually impede the sharing of health IT-related safety events. T is is best explained by example: Consider a nurse, Sue, who notices that a patient was prescribed penicillin, to which he is allergic. Glad to have caught this problem before ad- ministering the drug, Sue follows her hospital’s process to report this “near miss” to a PSO. In investigating the issue, the hospital’s risk manager discovers that the prescribing physician made an error by failing to consult the patient’s medication allergies before ordering the medication. At the same time, his EHR also failed to trigger the pop-up alert


Stephanie Zaremba, Senior Manager of Government and Regulatory Affairs, athenahealth, Inc.

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