Hardware and software: required to run the healthcare applications | Computer or network is not functioning | Provide redundant hardware for all essential patient care activities |
Input data truncated (i.e., buffer overflow): some entered data lost | Warn users when data entered exceed amount that can be stored |
Clinical content: data, information, and knowledge entered, displayed, or transmitted | Allowable item cannot be ordered (e.g., no amoxicillin in the antibiotic pick list) | Conduct extensive prerelease testing on all system–system data interfaces and human–computer interfaces to ensure that new features are working as planned and that existing features are working as before |
Incorrect default dose for given medication |
Human–computer interface: aspects of the system that users can see, touch, or hear | Data entry or review screen does not show complete data (e.g., missing patient name, medical record number, birthdate) | Encourage and provide methods for clinicians to report when patient-specific screens do not contain key patient demographics so that the software can be fixed |
Two buttons with same label but different functionality | Prerelease inspection of all screens for duplicate button names |
Wrong decision about KCI administration based on poor data presentation on the computer screen | Improve data displays and train users to routinely review and cross-validate all data values for appropriateness before making critical decisions |
People: the humans involved in the design, development, implementation, and use of HIT | Two patients with same name: data entered for wrong patient | Alert providers to potential duplicate patient names and require reconfirmation of patient identity before saving data (e.g., display patient photo before signing) |
Incorrect merge of two patients' data | Develop tools to compare key demographic data and calculate a probability estimate of similarity |
Nurses scan duplicate patient bar code taped to their clipboard rather than bar code on patient to save time | Improve user training, user interfaces, work processes, and organizational policies to reduce need for workarounds |
Workflow and communication: the steps needed to ensure that each patient receives the care he or she needs at the time he or she needs it | Computer discontinues a medication order without notifying a human | Implement fail-safe communication (e.g., resend message to another hospital designee if no response from physician or nurse) for all computer-generated actions |
Critical abnormal test result alerts not followed up | Implement robust quality assurance systems to monitor critical alert follow-up rates; use dual notification for alerts judiciously |
Organizational policies and procedures: internal culture, structures, policies, and procedures that affect all aspects of HIT management and healthcare | Policy contradicts physical reality (e.g., required bar code medicine administration readers not available in all patient locations) | Before and after implementation, conduct inspections and interviews and monitor feedback from users in all physical locations |
Policy contradicts personnel capability (e.g., one pharmacist to verify all orders entered via CPOE in large hospital) | Before and after implementation, conduct interviews with all affected users to better gauge workload |
Incorrect policy allows “hard stops” on clinical alerts, causing delays in needed therapy | Disallow “hard stops” on almost all alerts; users should be able to override the computer in all but the most egregious cases (e.g., ordering promethazine as intravenous push by peripheral vein) |
External rules, regulations, and pressures: external forces that facilitate or place constraints on the design, development, implementation, use, and evaluation of HIT in the clinical setting | Billing requirements lead to inaccurate documentation in EHR (e.g., inappropriate copy and paste) | Highlight all “pasted” material and include reference to source of material |
Joint Commission—required medication reconciliation processes causing rushed development of new medication reconciliation applications that were difficult to use and caused errors: safety goal rescinded only to be reinstated July 1, 2011 | Carefully consider potential adverse unintended consequences before making new rules or regulations: conduct interviews and observations of users to gauge effects of rules and regulations on patient safety, quality of care, and clinician work life |
System measurement and monitoring: evaluation of system availability, use, effectiveness, and unintended consequences of system use | Incomplete or inappropriate (e.g., combining disparate data) data aggregation leads to erroneous reporting | Increase measurement and monitoring transparency by providing involved stakeholders with access to raw data, analytical methods, and reports |
Incorrect interpretation of quality measurement data |