Develop and Validate Health IT Safety Measures To Capture Violations of the Five Rights of Medication Safety

The 2011 Institute of Medicine (IOM) report, Health IT and Patient Safety, raised awareness of new patient safety risks introduced by health information technology (IT) systems. However, it noted a lack of evidence quantifying the magnitude of these risks due to inadequate systems for capturing health IT safety events. As part of its recommendations, the IOM called for the Agency for Healthcare Research and Quality (AHRQ) to fund the development of “new measures for reliably assessing the current state of health IT safety and monitoring for improvements.”

This project will expand the use of a previously validated measure, the “Wrong-Patient Retract-and-Reorder (RAR) Measure,” to develop health IT measures needed for identifying violations of the “Five Rights of Medication Safety”: right patient, right dose, right medication, right route, and right frequency. For example, the “Wrong-Dose Retract-and-Reorder Measure” will identify an order placed on a patient that is retracted within 10 minutes and then placed by the same clinician on the same patient, but with a different dose within the next 10 minutes.

The specific aims of this project are as follows:

• Develop and pilot effective and valid measures for detecting wrong-dose, wrong-medication, wrong-route, and wrong-frequency electronic orders in an acute care setting, by extending the wrong-patient Retract-and-Reorder automated detection method. 
• Implement the automated measures developed in the first aim at a second hospital, using a different electronic health record, to evaluate the reliability of the measures. 
• Conduct a multisite observational study describing the overall frequency of wrong-patient, wrong-dose, wrong-medication, wrong-route, and wrong-frequency electronic orders and describe the frequency in subgroups characterized by provider, patient, and system factors. 

An advisory panel of health IT and medication safety experts will develop measure specifications for each proposed measure to be implemented and validated. These specifications will be implemented to create a real-time list of RAR events for each measure. In order to assess each measure’s accuracy, 200 of the automatically identified RAR events per measure will be confirmed via telephone interviews. Refinements to the measure will be made until 75 percent of the time automated identification of an event is confirmed to be a true event. The final measures will be implemented and revalidated at two separate hospital settings to test if the measures are reliable and remain valid when implemented in different EHRs. The final measures will be applied to describe the overall frequency of wrong-patient, wrong-dose, wrong-medication, wrong-route, and wrong-frequency errors at both institutions and describe the frequency among specific subgroups characterized by provider, patient, and system factors.

Once developed, these new measures will be ready for endorsement by the National Quality Forum (NQF) and may be used to evaluate the effectiveness of interventions aimed at preventing some of health IT’s most serious and complicated safety issues.