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New ECRI report highlights ways to avoid diagnostic errors

por John R. Fischer, Senior Reporter | July 31, 2018
Health IT
A new report by ECRI Institute's partnership
collaboration suggests ways to avoid
testing errors and medication mix-ups
There are several ways to reduce or eliminate diagnostic testing errors and medication mix-ups with information technology. Just read Health IT Safe Practices for Closing the Loop, the latest report on the matter issued by ECRI Institute’s Partnership for Health IT Patient Safety.

Based on data logged in ECRI Institute’s patient safety organization database of more than two million adverse events, and methodical analysis by a Partnership workgroup, the report outlines practices for using health IT to reduce missed, delayed and incorrect diagnoses for diagnostic results as well as incorrect medication changes.

“People anticipated that technology use would automatically improve safety – to some extent it has,” ECRI Institute’s Lorraine Possanza, program director of the Partnership for Health IT Patient Safety, and Patricia Giuffrida, a patient safety analyst and HIT liaison, told HCB News. “But some areas require additional focus. Closing the loop is one area where technology has not reached its full potential.”

Laboratory testing and imaging studies are the most common areas for diagnostic errors in clinical settings, brought on by gaps in the process such as untransmitted orders, patients not being notified, or when results are not returned or reviewed fully due to slower transmission of certain parts.

For medication, one of the most common issues is when a provider discontinues one but the message is not sent to the pharmacy which continues refilling it, possibly placing the patient at greater risk for serious injury or damage.

The workgroup devised the fourth edition of its toolkit report with a focus on three tenants: communication, tracking, and connecting acknowledgement with action.

In it, they call on providers to enhance communication by implementing and modifying existing EHR functions to automate the notification process. Doing so, they claim, will improve the delivery of results, including for critical findings messaged in automatic alerts to providers. The mechanism used for this should be separate from the one used to transmit noncritical and non-urgent results.

They also recommend standards such as Logical Observation Identifiers Names and Codes for automated result matching of ordered tests, which optimizes and automates tracking of diagnostic conclusions, enabling better mapping.

For linking acknowledgement to action, the group suggests making message notifications for diagnostic results modifiable, so that recipients can add actions performed to close the loop.

“These three recommendations each have specific steps that stakeholders can take to close the loop. It is important to close the loop so that diagnoses are timely, accurate, and correct,” Possanza and Giuffrida said. “This will ensure that the necessary information is available so that the diagnoses and changes made in treatment regimens are known to providers and patients, mitigating those incorrect, missed and delayed diagnoses by making certain that information is communicated, tracked and linked to action.”

The Partnership for Health IT Patient Safety is a multi-stakeholder group overseen by the ECRI Institute that leverages the expertise of health IT developers, providers, PSOs, patients and healthcare professionals to determine the safest uses of technology and the best approaches in their use for improving patient safety.

The toolkit is available for use worldwide.

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