Law & Governance
Top 10 Patient Safety Myths
- MYTH: CPOE alone can improve patient safety.
While Computerized Physician Order Entry (CPOE) has been helpful minimizing errors associated with medication orders, it is only one piece of the overall patient safety solution. Healthcare executives should consider how their technology supports safety across the entire enterprise and realize that anytime you add new technology, change a process, or both, you can 1) enhance safety and reduce certain errors, 2) introduce new errors into the system, and 3) make some errors - either new or existing - harder to detect. Executives must build a quality program around any project that affects their IT and/or care processes.
- MYTH: My vendor understands patient safety.
Patient safety is a relatively new discipline. Unfortunately there are very few individuals who understand patient safety's key issues and approaches, and can match that with experience to make it relevant for you and your health system. It is important to note that, to date, HIM vendors have had limited success with physician adoption of CPOE and nurse usage of clinical documentation systems. Therefore, while vendors may know their systems' capabilities, they do not have much experience with how the technology is actually used and the implications for patient outcomes. It is important to 'do your homework' and learn as much as you possibly can before entering into a vendor partnership.
- MYTH: Return-on-investment is the reason to address patient
Don't build your ROI based on safety alone. Common folklore aside, it is impossible to directly measure any financial benefit from patient safety initiatives. Instead, consider investing in technology as a way to improve on patient safety while it improves your bottom line in other ways, such as decreasing lengths of stay or providing less expensive formulary medication choices.
- MYTH: Implementing an advanced clinical system will mean
Beware the vendor story that "our system will provide you enough rules and alerts that you can reduce or remove certain people from your processes." No clinical system contains enough current information to replace human decision-making, nor will these systems reach that level of functionality in the span of their product lifetimes.
- MYTH: If we build it, they will come.
Trying to bring physicians on board after a clinical system has been selected and implemented is a common, and quite often, costly mistake. Do not expect anyone to "heal your pain" if you take a step that affects your medical and nursing staffs without their involvement and participation upfront. At the start of the process, pull together an interdisciplinary team of clinicians to help you choose the best solution that will support their work as well as create a patient safety environment.
- MYTH: Everyone else has a patient safety problem - except
When surveyed, most healthcare leaders believe that patient safety is a major issue in the United States - but not at their facility. If you can imagine an error occurring when reflecting on how your organization delivers care, it can, probably will or even has already happened. A good way to begin the journey is to start with a realistic expectation - that your system has much work to do to improve reporting and enhance safety.
- MYTH: Benchmarking will define where we should start
We are still early in our development of advanced reporting systems for capturing medical errors. Until we have mature reporting systems and fully institute a culture where reporting errors is less threatening, we can't really get the full picture of where medical errors may and have occurred. If you rely on existing and incomplete benchmarketing data, it may hurt - and not help - your efforts.
- MYTH: Patient safety requires a new corporate
If you want to make lasting change in your organization, patient safety should be part of the organizational "genome." Instead of creating another large "siloed" department with new positions that focus solely on safety, let patient safety become an integral part of all processes - part of the organizational fabric in everything you do. Consider the benefits here every employee is connected with a "Safety First" corporate culture.
- MYTH: It's okay to store almost all of our patient data on
an outpatient system because that is how most receive
Since there are no standards to carry "hard coded" critical system messages between vendor systems, the usefulness of "best of breed" systems is limited. Though a patient experiences the majority of their care as an outpatient, storing rich patient data on an outpatient system that can not be extended into an inpatient or longterm care system creates a major gap through which safety issues can likely arise.
- MYTH: Most medication errors occur at the order writing
stage of the process.
Are you positive that none of your errors are occurring when medication is dispensed? Or during its administration? Before implementing a CPOE system, which requires a financial investment and change in established processes, you must undergo a careful study of your existing system.
About the Author(s)
Dr. Brian Shea was project manager of CGE&Y's patient safety project and has dedicated his entire career to improving the materials and standards applied by the pharmacy and physician communities to improve a patient's safety. He has served as the Secretary of the Pharmacy and Therapeutics Committee at Brigham and Women's Hospital and as a member of the Harvard ADE Prevention Study Group. Elected a fellow of the American College of Clinical Pharmacy in 1997, Dr. Shea has published various articles on safety throughout his career, including co-authored studies on medication errors that appeared in Journal of the American Medical Association, and articles on patient safety in Advance for Health Information Executives and Healthcare Informatics (upcoming).
AcknowledgmentReprinted with permission from Cap Gemini Ernst & Young Health.
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