Medication safety problems are a leading cause of injury and preventable harm in a hospital-based setting. Although electronic health records that include computerized physician-order entry and clinical-decision support can help to protect patients from adverse events, a new study finds that many EHR safety issues still remain.
The study, conducted by researchers from the University of Utah and the Brigham and Women’s Hospital and published in the Journal of the American Medical Association, used a CPOE evaluation tool to assess EHR performances at more than 2,000 hospitals over the course of 10 years. “Despite broad adoption and optimization of EHR systems in hospitals, wide variation in the safety performance of operational EHR systems remains across a large sample of hospitals and EHR vendors,” wrote the researchers.
WHY IT MATTERS
Researchers used test scenarios based on real-world orders that have previously killed or injured patients to measure how thoroughly hospital EHRs could flag potentially harmful errors.
“To participate in this high fidelity test, a hospital representative downloads and enters a set of test patients with detailed profiles, including diagnoses, laboratory test results, and other information, into their EHR as real patients would be admitted to their hospital,” the researchers explained. A clinician then enters test medication orders for these hypothetical patients, the study continued, and records how the EHR responded – “including what, if any, CDS in the form of alerts, messages, guidance, soft or hard stops, or other information are presented and whether the order is blocked or allowed to be entered in the EHR system.”
The biggest improvement over the course of ten years was in orders with potential adverse events that would be prevented with basic CDS, such as drug-allergy. Those requiring advanced CDS, such as drug-age, were less successful at generating alerts, warnings, or soft or hard stops.
Although the mean hospital score rose somewhat over the course of ten years, there was dramatic variation in EHR performance from facility to facility and from vendor to vendor. Researchers also noted that the biggest EHRs in terms of market share weren’t necessarily the safest: The second–most popular EHR had among the lowest safety scores. The study also noted that all nine vendors were used by at least one hospital that achieved a perfect safety score.
THE LARGER TREND
Safety groups cited alert fatigue as a top tech health concern for 2020, with an influx of CDS alerts muddling important messaging beyond legibility or notice. The Agency for Healthcare Research and Quality pointed out in 2015 that clinicians “generally override the vast majority of CPOE warnings, even ‘critical’ alerts that warn of potentially severe harm.”
“Alert fatigue increases with growing exposure to alerts and heavier use of CPOE systems. This finding is intuitive, but also raises the important implication that without system redesign, the safety consequences of alert fatigue will likely become more serious over time,” the AHRQ continued. EHRs can improve patient safety. However, as the JAMA study noted, several hospitals achieved perfect scores over the course of ten years. But they must be optimized effectively, with accurate information inputs.
ON THE RECORD
“Hospitals, EHR vendors, and policy makers can seek to improve safety performance in several ways,” advised researchers. “First, hospitals should consider performing some type of CPOE safety evaluation at least annually or after upgrades and work to address identified shortcomings. Continuous assessments are also critical to identify unanticipated problems that may occur as systems are updated and customized,” they wrote.
“They should also share these results with their EHR vendor to help these vendors create safer products, as safety is a shared responsibility between vendors and hospitals,” they continued. Finally, they said, “policymakers may wish to include CPOE safety evaluation scores in their suite of process quality measures reported publicly.”
