Dr. Brita's Blog

Why process improvement, technology and common sense are critical to patient safety

Posted by Dr. Brita Hansen on May 3, 2018 12:50:00 PM
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Patient safety is the number one concern of any healthcare provider, yet the tools put in place to help guide clinicians in providing appropriate care are often hindering it. Whether it’s out-of-date or confusing workflows documented in electronic health record (EHR) systems or difficulty in using the systems themselves, the technology does not always contribute to better patient care. Process improvement and common sense must be applied to ensure quality of care.

I’ve read several articles on this topic recently all published in March 2018 that I think are worth sharing. Each points to the need for process, technology and critical thinking. The first, Medical staff lacked ‘critical thinking’ in accidental overdose, coroner finds, involves a patient who was given the wrong medication and died from a drug overdose six hours after knee surgery. Hospital staff missed more than 15 opportunities to spot the problem, according to the coroner’s report, which recommended changes to the hospital’s EHR to strengthen patient verification methods and modifications to hospital procedures for administering medication.


The second piece, about a study that revealed EHR usability issues can pose a danger to patient safety, appeared in JAMA Network and was also featured on msn.com. Researchers reviewed reports from the Pennsylvania Patient Safety Authority database containing information from more than 570 healthcare facilities. They found nearly 2,000 safety events that specifically mentioned EHR usability as a contributing factor and more than 550 that explicitly said EHR usability problems had put patients at risk. Examples include the EHR allowing a clinician to record a child’s weight in kilograms rather than pounds, which could have led to dangerous overdoses of medications measured by weight, and failure to alert doctors and nurses to life-threatening conditions, such as drug allergies. Fixing errors in the EHR through process improvement and well-trained, sharp-eyed clinical staff both are essential for improving patient safety.

The third item I highly recommend reading is an opinion piece by my colleague, Patrick Yoder. Small changes could reap big rewards in fixing the opioid crisis, published in Market Watch, focuses on the potential of EHRs as a valuable tool in tackling the opioid epidemic. The data captured in these Opioid Clinical Process Module Webpage systems should be put to work to improve the clinical treatment of pain and decrease the variability in how opioids are prescribed. These changes can be both proactive (directing hospital staff protocols) and reactive (identifying where opioids are overused). As Patrick explains, the opioid crisis largely stems from broken processes that guide clinicians to write too many prescriptions. Improving the use of EHR systems in the following ways would make significant inroads in cutting the endemic overuse of opioids: reviewing clinical protocols, changing order sets, reducing flexibility and change alerts, ending open-ended prescriptions and analyzing data. Be sure to read the entire article about how better use of EHR systems and the workflows in them guiding care is the key. Read more on LogicStream Health's Opioid Management Clinical Process Module by clicking the button below or check out last week's blog post.

Opioid Management Clinical Process Module

We all have a role to play in improving patient care through the processes and technology that help guide care delivery and the critical thinking to recognize when processes and technology need to change.

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Topics: Appropriate Utilization, Quality & Safety

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Brita Hansen, MD, is Chief Medical Officer at LogicStream Health. Dr. Hansen is also a practicing internal medicine hospitalist and has served as a healthcare system executive, most recently as Chief Health Information Officer at Hennepin County Medical Center in Minneapolis. Dr. Brita’s Blog covers a range of topics, including:

  • Appropriate Utilization
  • Clinician Engagement
  • Clinical Process Performance & Improvement
  • Healthcare Information Software & Technology
  • EHR Optimization
  • Clinical Decision Support
  • Healthcare Patient Safety & Quality

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