Study: Drug Problems Most Common EMR Safety Event

When the phrase “EMR problems” comes to mind, most of us get a  mental image of hardware flaws, software bugs or integration problems. But according to a new study, the majority of EMR-related patient care problems stem from issues in how people interact with their system, specifically in documenting and administering medication.

In recent research, the Pennsylvania Patient Safety Authority queried the state’s patient safety reporting database to identify EMR-related events. After sifting out events that didn’t truly appear to be EMR-related, analysts were left with 3,099 patient safety issue reports. The events were then classified by the harm score assigned by the reporter.

As it turns out, the great majority of events (89%) resulted in no harm to the patient. Ten percent of events were reported as “unsafe conditions” but also resulted in no harm to the patient.  Fifteen events actually resulted in temporary harm to the patient:

* Six cases of entering wrong medication data
* Three cases of administering the wrong medication
* Two cases of ignoring a documented allergy
* Two cases of failure to enter lab tests
* Two cases of failure to document

The only event that resulted in significant harm stemmed from failure to properly document an allergy, analysts said:

Patient with documented allergy to penicillin received ampicillin and went into shock, possible [sic] due to anaphylaxis. Allergy written on some order sheets and “soft” coded into Meditech but never linked to pharmacy drug dictionary.

All told, medication errors were the most commonly reported event (81 percent), largely wrong-drug, dose, time patient or route errors (50 percent) or omitted dose (10 percent).

It’s worthy of note that according to the researchers, the narrative reports of EMR-related reports dug up from the Pennsylvania database differed meaningfully from reports found in FDA database MAUDE and Australia’s Advanced Incident Management System, which have different reporting requirements.

It seems that there’s a lot more work to be done in exposing the types of patient safety errors that may be unique to EMRs, but this looks like a good start.