pennsylvania patient safety authority report examines dangers of electronic medical records

The Pennsylvania Patient Safety Authority — the independent state agency “charged with taking steps to reduce and eliminate medical errors by identifying problems and recommending solutions that promote patient safety” — recently concluded a rather alarming study concerning the prevalence of patient safety incidents related to electronic medical records here in the Keystone State.

Researchers determined that the number of patient safety incidents related to EHRs more than doubled from 2010 to 2011 (the most recent year for which complete data is available), climbing from 555 to 1,142. They also determined that since 2004 there have been a total of 3,099 patient safety incidents related to EHRs.

As if this wasn’t alarming enough, the researchers determined that 16 of these safety incidents resulted in some sort of patient injury, including one that was classified as resulting in “significant patient harm.”

Here, a patient went into anaphylactic shock after being administered penicillin, a drug to which they were allergic. Investigators later determined that while the allergy had been noted in the patient’s electronic medical record, it was not entered in the field reserved for known drug allergies, meaning the system was unable to block the drug from being ordered.

The Patient Safety Authority also took the liberty of categorizing the 3,099 patient safety incidents, providing invaluable insight into how exactly these medical mistakes occurred:

  • 47 percent could be attributed to incorrect input by medical professionals
  • 33 percent could be attributed to system problems (display errors, missing data, data loss, alert failures, etc.)
  • 18 percent could be attributed to failures to properly update the EHRs with critical information available elsewhere

It is worth noting that some experts believe that this is only the tip of the iceberg since 1) the Patient Safety Authority report was based on purely on voluntary reports and 2) medical professionals may sometimes be completely unaware that a patient safety incident is related to EHRs.

“These systems are incredibly complex,” said Dr. Scot Silverstein of Drexel University. “They’re not just huge filing cabinets, they are enterprise resource management systems. There are many ways that things can go wrong that may not be seen as the computer having caused the mess-up in the first place.”

Clearly this study serves as yet another reminder of how far EHRs have to go before they can — and should — be considered reliable by medical professionals. While some may say that 16 incidences of patient harm over roughly seven years is an acceptable number, the reality is that it’s still too high. Far more work needs to be done to perfect the EHR system and, more importantly, protect patient safety.

Source: American Medical News, “EHR-related errors soar but few harm patients,” Kevin O’Reilly, Jan. 14, 2013

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