Although there are hundreds of electronic health record (EHR) systems, each with different functions and designs, their basic job is to make it easier for everyone on your staff to provide comprehensive care for all of your patients.
But no matter how robust or intuitive your system is, if you and your staff can’t effectively use it, patient care ultimately suffers.
Check out this example from the Partnership for Health IT Patient Safety, a national collaborative that the Texas Medical Association is a part of:
An elderly female patient was receiving electroconvulsive therapy (ECT) – a carefully controlled amount of electricity directed at a specific area of the brain – for severe mental illness. ECT is administered under anesthesia and with muscle relaxant medications.
During the 8th ECT treatment, the patient received two anesthesia medications – methohexital 170 mg (anesthetic used to put a patient to sleep before the procedure) and succinylcholine 140 mg (paralytic that relaxes muscles during the procedure). The treatment was documented as uneventful.
Prior to this patient's 9th ECT treatment, the anesthesia provider and post-anesthesia care unit staff reviewed the electronic anesthesia report from the 8th ECT treatment to identify the medications and medication doses administered. The anesthesia report included a medication grid display.
The clinicians looked at the grid and, mistakenly reading the numbers as two digits, interpreted the doses as methohexital 70 mg and succinylcholine 40 mg (instead of 170 mg and 140 mg, respectively). These lower doses were administered during this subsequent treatment. The patient experienced an unanticipated reaction to the 9th procedure and required the administration of an IV sedative to alleviate agitation and delirium.
In this case, multiple factors might have contributed to the error, including low lighting, the size of the monitor, and the color of the text compared with the color of the grid lines.
To help you prevent these types of errors in your practice, TMA has created a Technology and Patient Safety webpage that includes articles, interactive tools, manuals, and guidelines on how to make your EHR technology safer.
Use it to find information on contracting with EHR vendors, implementing or switching systems, and keeping your system secure.
If you have questions, you can always contact TMA’s HIT Helpline via email or at (800) 880-5720.