Context is Critical: Understanding When and Why Electronic Health Record Related Safety Hazards Happen (Maryland)

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Most research on the safety of electronic health records (EHRs) has focused on the identification and classification of specific types of errors. Other high-risk industries, like aviation, have focused on the conditions under which errors occur, and have often put technological systems in place to capture the context around errors. For instance, flight data recorders--“black boxes”--provide context for aviation events, allowing for a robust retrospective analysis of events. This methodology has led to providing better designs and preventing predictable errors in aviation.

This project will test the feasibility of using a black box methodology applied to EHRs by recording the real-time use of EHRs by physicians in the clinical setting, and analyzing medication errors in the context in which they occurred. From this, the specific design elements that contributed to the errors will be evaluated, and recommendations around future EHR design will be made to mitigate those errors.

The specific aims of the project are as follows:

  • Identify and characterize potential EHR-facilitated error patterns from clinical EHR data, including wrong patient, wrong medication, and wrong route errors. 
  • Analyze the context of the error through video review and systematically categorize the observed errors to understand what factors lead to EHR-facilitated errors. 
  • Identify the specific EHR design elements facilitating the errors, create data-driven design guidelines based on the most common error causing elements, and disseminate findings to diverse stakeholders, including providers and EHR developers. 

MedStar Health System, a 10-hospital system serving the Baltimore and Washington, DC, region, will serve as the setting for this project. Using a previously implemented system that records video of each EHR interaction, the project team will develop a method to review and analyze those interactions in the clinical environment, analyze the context around errors, identify the EHR design elements that contributed to errors, and create recommendations around how to mitigate those errors in the future.

In addition to establishing the feasibility of using such a methodology similar to the flight black box in aviation, this project has the potential to create evidence-based recommendations for safer EHR design that may be useful to all stakeholders, including healthcare teams, EHR vendors, and organizations associated with standards and policymaking around safe and usable EHRs.

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Blackbox: A Multidisciplinary Team-Based Framework for HIT Error Pattern Detection - Final Report

Hettinger A. Blackbox: A Multidisciplinary Team-Based Framework for HIT Error Pattern Detection - Final Report. (Prepared by MedStar Health Research Institute under Grant No. R21 HS024755). Rockville, MD: Agency for Healthcare Research and Quality, 2019. (PDF, 492.54 KB)

The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
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