How can this be? Technology, after all, is supposed to reduce adverse drug events, not be a root cause.
“Technologies that target each point of the medication-use process have been developed to reduce the likelihood of errors reaching the patient,” the report said. “These technologies include computerized prescriber order entry systems, pharmacy information systems, automated dispensing cabinets, barcode medication administration, and ‘smart’ infusion pumps, which incorporate dose error reduction systems with comprehensive drug libraries containing information on usual concentrations, dosing units, and dose limits.”
What the Pennsylvania Patient Safety Authority discovered was that patient safety technology begets the need for even more patient safety technology, as new, often unforeseen types of errors are now occurring. In the case of the 889 medication errors cited in the report, 33% were attributed to the human-computer interface, 24% to workflow and communication, and 23% to clinical content.
The Need for Improved Incident Reporting
To identify and prevent errors attributed to healthcare information technology, the report listed no fewer than 28 strategies, the first of which was:
Encourage individuals to report unsafe conditions, near misses, and errors due to healthcare information technology so these concerns can be analyzed and ameliorated.
This strategy is not new. In fact, it was first suggested in 2008 by The Joint Commission in its “Sentinel Event Alert, Issue 42: Safely implementing health information and converging technologies.”
So, if robust incident reporting has been a mainstream medication error reduction strategy for a decade, why hasn’t more been done?
The fact is, more has.
How Datix is Solving the Incident Reporting Problem
Datix has been improving incident reporting in hospitals worldwide for years, designing and deploying technology that protects patients from adverse drug events through active surveillance that promotes a safety culture that encourages self-reporting of errors and near misses. Our online incident reporting form – just one cog on the Datix patient safety toolkit – was designed in real-world environments in consultation with our users to ensure it is not only simple to use, but also suitable for both clinical and non-clinical incident reporting. The user interface can be personalized to the needs and workflows of the organization, and incidents can be easily submitted by anyone in the organization with access to a computer.
Datix Incident Reporting gives you the flexibility to configure your data dictionary, forms, and workflows according to your organization’s priorities. The powerful Datix Common Classification System aligns with the AHRQ Common Formats and other international standards. Datix also tracks submissions to patient safety organizations, such as the Pennsylvania Patient Safety Authority.
But that’s not what makes our incident reporting functionality so powerful.
Datix Incident Reporting combines with Datix Safety Alerts to provide teams with daily huddle topics that include local incidents and near misses, enterprise level alerts, and lessons learned to ensure the spread of improvements and awareness.
In addition, by automatically and immediately routing event reports according to categories, areas involved, and risk improve triage and investigation time, allowing safety professionals to shift their efforts from chasing investigative tasks to improving safety with team leaders. When teams see timely and consistent responses to the events they report, safety culture improves, which helps avoid future, potential adverse drug events.
Our ability to promote a patient safety culture through technology is just one reason why Datix is the global leader in risk management technology. We maintain an intense focus on reducing not only adverse drug events at healthcare organizations worldwide, but also all preventable patient harm. If you want to leverage technology to reduce medication errors – or improve any aspect of your patient safety program – then we would welcome a conversation. We work only in healthcare, which will provide you with a level of expertise you won’t find anywhere else. Let’s get to work.