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Patient Safety Learning

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  1. Patient Safety Learning
    An independent inquiry is expected to call for major changes in the way private hospitals supervise doctors after hundreds of women were put through unnecessary operations by a rogue breast surgeon.
    Ian Paterson was jailed for 20 years in 2017 after being convicted of 13 counts of wounding with intent and three counts of unlawful wounding. But his surgical malpractice may have harmed more than 750 women over more than a decade.
    He carried out unnecessary surgery for breast cancer on women who did not have the disease, and put other women who did at risk by using his own unofficial technique, which left behind partial breast tissue.
    On Tuesday an inquiry chaired by the Bishop of Norwich, the Right Reverend Graham James, will be published and is expected to make recommendations about how doctors are allowed to work across both the NHS and private sector with minimal supervision and oversight.
    One key area of focus is expected to be a process known as “practising privileges”, where private hospitals allow clinicians to carry out their own activities within the hospital, similar to self-employed contractors. They effectively rent the hospital space for their work.
    Read full story
    Source: The Independent, 2 February 2020
  2. Patient Safety Learning
    Healthcare apps that triage patients should be put through a ‘fair test of clinical performance’ published by NHS England to ensure their safety, according to the Care Quality Commission (CQC).
    In addition, the Department of Health and Social Care should look into whether ‘safety-netting’ advice should be available to the public about how to use symptom checkers, said the CQC.
    The CQC made the recommendations as part of work to shape its approach to regulating healthcare apps. It found digital triage tools are currently not fully clinically validated or tested by product regulators and discovered ‘there is great variation in their clinical performance’.
    NHS England and other bodies should assess where people have been wrongly escalated, resulting in undue anxiety, as well as where tools have failed to address people’s ill health, said the CQC.
    Read full story
    Source: PULSE, 30 January 2020
  3. Patient Safety Learning
    A nurse from South Gloucestershire died after doctors missed signs of her cervical cancer amid a series of "gross" failings, a coroner has ruled.
    Julie O’Connor’s cancer was not picked up by North Bristol NHS Foundation Trust despite abnormalities in a smear test in 2014 and a biopsy in 2015. She went for multiple further checks for gynaecological problems in 2016 and 2017 and was referred three times to specialists. However, Ms O'Conner only received a cancer diagnosis once she decided to seek private treatment at Spire Hospital in Bristol.
    An inquest into her death was held in Flax Bourton, Somerset, this week.
    Maria Voisin, Senior Coroner for the Avon area, found the cause of Ms O’Connor’s death to be of “natural causes contributed to by neglect". She recorded three instances of "gross failures" including the inaccurate smear test as well as mistakes in two further assessments.
    Deputy medical director Tim Whittlestone said: “We accept the findings of the coroner and support her actions to build on our correspondence with the Royal College of Obstetricians and Gynaecologists."
    “...I would like to reaffirm that North Bristol has investigated these errors and more importantly that we have learnt lessons from our mistakes."
    Read full story
    Source: Nursing Times, 31 January 2020
  4. Patient Safety Learning
    Children’s cancer services in south London are to be reconfigured after a new review confirmed they represented an “inherent geographical risk to patient safety” — following HSJ revelations last year of how serious concerns had been “buried” by senior leaders.
    Sir Mike Richards’ independent review was commissioned after HSJ revealed a 2015 report linking fragmented London services to poor quality care had not been addressed, and clinicians were facing pressure to soften recommendations which would have required them to change.
    The review, published in conjunction with Thursday’s NHS England board meeting, recommended services at two sites should be redesigned as soon as possible to improve patient experience.
    Read full story (paywalled)
    Source: HSJ, 31 January 2020
  5. Patient Safety Learning
    Two people have tested positive for coronavirus in the UK, the Chief Medical Officer for England has announced.
    They are both members of the same family and are receiving specialist NHS care. No more details are being released about their identity or where they are being treated.
    At least 213 people in the China have died from the virus, mostly in Hubei, with almost 10,000 cases nationally. There have been 98 cases of the virus in another 18 countries.
    Prof Chris Whitty, Chief Medical Officer for England said: "The NHS is extremely well-prepared and used to managing infections and we are already working rapidly to identify any contacts the patients had, to prevent further spread. "We have been preparing for UK cases of novel coronavirus and we have robust infection control measures in place to respond immediately," he added.
    Prof Whitty said the UK was working closely with the World Health Organization (WHO) and the international community as the outbreak in China develops "to ensure we are ready for all eventualities".
    The new coronavirus was declared a global emergency yesterday by the World Health Organization, as the outbreak continues to spread outside China.
    "The main reason for this declaration is not what is happening in China but what is happening in other countries," said WHO Chief Tedros Adhanom Ghebreyesus.
    The concern is that it could spread to countries with weaker health systems.
    Read full story
    Source: BBC News, 31 January 2020
  6. Patient Safety Learning
    Levels of self-harm in prisons have hit a new high, with more than 60,000 incidents in a year, official figures show.
    The number of self-harm incidents was up 16% to 61,461 in the 12 months to September 2019, when there were 53,076, according to data released by the Ministry of Justice (MoJ).
    Prison reform campaigners have criticised the government for failing to respond effectively to serious mental health problems and called Thursday’s figures a “national scandal”.
    Deborah Coles, the Director of the charity Inquest, said: “Despite investment and scrutiny, the historical context shows that still more people are dying in prison than ever before. A slight recent reduction in the number of deaths comes alongside unprecedented levels of self-harm, while repeated recommendations of coroners, the prison ombudsman and inspectorate are systematically ignored."
    "This is a national scandal and reflects the despair and neglect in prisons. Despite this, the health and safety of people in prison appears to be very low on the agenda of the new government."
    Read full story
    Source: 30 January 2020
  7. Patient Safety Learning
    A new report published by the National Guardian’s Office reveals that the perception of the speaking up culture in health is improving.
    An annual survey, conducted by the National Guardian’s Office, asked Freedom to Speak Up Guardians, and those in a supporting role, about how speaking up is being implemented in their organisation. The results reveal details about the network’s demographics and their perceptions of the impact of their role.
    Headlines from the survey include a measure of whether those in speaking up roles think their work is making a difference, with 76 per cent agreeing or strongly agreeing – compared to 68 per cent last year. They also reported that awareness of the guardian role is improving.
    “It’s really important we listen to guardians in order to understand the impact Freedom to Speak Up is making,” said Dr Henrietta Hughes OBE, National Guardian for the NHS. “The report we are publishing today will help organisations better understand how to work with their guardians to improve their speaking up cultures.”
    Read full story
    Source: National Freedom to Speak Up, 30 January 2020
  8. Patient Safety Learning
    More than half of all incidents resulting in death reported by health boards in Wales came from troubled Betsi Cadwaladr. The 53% figure from a Welsh Government safety report came to light during First Minister Questions in the Senedd yesterday.
    Plaid Cymru Leader Adam Price said there had been “an alarming rate” of patient safety incidents in the Betsi Cadwaladr University Health Board area and that between December 2018 and November 2019 there were 40 incidents resulting in death registered within Betsi. Between November 2017 and November 2019 there were 520 incidents within Betsi that resulted in death or serious harm - higher than all the other health boards in Wales combined.
    Mr Price questioned whether there is an issue with Betsi itself, or whether there is an issue of "under-reporting of serious incidents" in the rest of Wales.
    Defending the figures, the First Minister said that reporting incidents and learning from them has become part of the culture of a health board that they “want to see everywhere in Wales”.
    Read full story
    Source: North Wales Live, 29 January 2020
  9. Patient Safety Learning
    In a keynote speech at the Healthtech Alliance on Tuesday, Secretary of State for Health and Social Care, Matt Hancock, stressed how important adopting technology in healthcare is and why he believes that it is vital for the NHS to move into the digital era. 
    “Today I want to set out the future for technology in the NHS and why the techno-pessimists are wrong. Because for any organisation to be the best it possibly can be, rejecting the best possible technology is a mistake.”
    Listing examples from endless paperwork to old systems resulting in wasted blood samples, Hancock highlights why in order to retain staff and see a thriving healthcare, embracing technology must be a priority.
    He also announced a £140m Artificial Intelligence (AI) competition to speed up testing and delivery of potential NHS tools. The competition will cover all stages of the product cycle, to proof of concept to real-world testing to initial adoption in the NHS.
    Examples of AI use currently being trialled were set out in the speech, including using AI to read mammograms, predict and prevent the risk of missed appointments and AI-assisted pathways for same-day chest X-ray triage.
    Tackling the issue of scalability, Hancock said, “Too many good ideas in the NHS never make it past the pilot stage. We need a culture that rewards and incentivises adoption as well as invention.”
    Read full speech
  10. Patient Safety Learning
    An advanced nurse practitioner working in primary care services at Grimsby Hospital has called on the hospital senior leadership to ‘see for themselves how unsafe it is’.
    The nurse, who has penned a letter to bosses at Northern Lincolnshire and Goole NHS Foundation Trust says they are having “worst experience to date” in their career and fears somebody will die unnecessarily unless something is urgently done.
    “I have never in my whole career seen patients hanging off trolleys, vomiting down corridors, having ECGs down corridors, patients desperate for the toilet, desperate for a drink. Basic human care is not being given safely or adequately," says the nurse.
    Hospital bosses say they are taking the letter seriously and are investigating. Earlier this month it was revealed that some hospitals were being forced to deploy ‘corridor nurses’ in a bid to maintain patient safety while dealing with unprecedented demand.
    Dr Peter Reading, Chief Executive, said: “I can confirm we have received this email and that the hospital and North East Lincolnshire CCG are taking these concerns seriously. The person who raised the concerns with us has been contacted and informed that we are jointly investigating what they have told us.
    Read full story
    Source: Nursing Notes, 22 January 2020
  11. Patient Safety Learning
    The hospital at the centre of a whistleblowing inquiry has been downgraded by the care watchdog and issued with a warning notice amid concerns over leadership and patient safety.
    West Suffolk Foundation Trust has been rated requires improvement by the Care Quality Commission (CQC) in a damning report having previously been rated outstanding since 2017.
    The trust, whose Chief Executive Stephen Dunn received a CBE for services to patient safety in 2018, has faced criticism after bosses threatened senior doctors with a fingerprint and handwriting analysis to try and identify a whistleblower.
    In a new report published today, the CQC inspectors said they had significant concerns about the safety of mothers and babies in the trust’s maternity unit and the criticised the culture of the trust leadership referencing what they called “threatening” actions.
    In the West Suffolk hospital maternity unit the CQC found staff had not completed key safety training, did not protect women from domestic abuse, and staff did not always report safety incidents. They also found maternity staff were not taking observations and the unit lacked enough staff with the right qualifications to keep women safe.
    The trust was issued with a warning notice by the trust demanding it make improvements before the end of this month.
    On the trust leadership the CQC report said: “The style of executive leadership did not represent or demonstrate an open and empowering culture. There was an evident disconnect between the executive team and several consultant specialities."
    Read full story
    Source: The Independent, 30 January 2020
  12. Patient Safety Learning
    Calls for immediate compensation for thousands of victims contaminated by infected NHS blood have been rejected by ministers at a meeting with campaigners and survivors – but more health support may be made available.
    Despite one person dying every four days on average from HIV, hepatitis C or other conditions, the government on Tuesday turned down a request for a national compensation scheme.
    There are estimated to be between 5,000 and 7,000 victims still alive who acquired viral infections through transfusions from the health service. Many are haemophiliacs who need regular transfusions to help their blood clot.
    Products supplied by the NHS in the 1970s and 1980s came from the US using blood obtained from prisoners and drug addicts who were paid for their donations. Imported products were inadequately screened.
    Read full story
    Source: The Guardian, 28 January 2020
  13. Patient Safety Learning
    The government has ordered an urgent inquiry into the local hospital of the health secretary, Matt Hancock, after the Guardian revealed its unprecedented “witch-hunt” for a whistleblower.
    The Department of Health and Social Care (DHSC) has told NHS England to commission a “rapid review” of the actions of bosses at West Suffolk hospital.
    They are under fire for demanding that staff give fingerprints and samples of their handwriting to help identify who wrote to a family alerting them to failings in care that contributed to a patient’s death.
    Unusually, the investigation has been instigated by Edward Argar, a junior minister at the DHSC, because Hancock and another health minister, Jo Churchill, are both local MPs who have close ties to the hospital.
    Argar has made clear to NHS England that the inquiry must be undertaken by independent experts, given those existing relationships.
    Announcing the review, Argar made clear that he wanted hospital personnel to speak openly. “I want all staff to feel that they can speak up and have the confidence that anything they raise will be taken seriously,” he said.
    Read full story
    Source: The Guardian, 28 January 2020
  14. Patient Safety Learning
    Nearly 35,000 patients are overdue a follow-up appointment at North Lincolnshire and Goole Foundation Trust, HSJ has learned.
    Almost 20% of the 34,938 follow-up appointments are in ophthalmology. A paper from the trust’s November board meeting said the “backlog of follow-up appointments… clearly remains a risk”.
    The report also said the service was failing some of the quality guidelines set out by the National Institute for Health and Care Excellence (NICE).
    The trust told HSJ it had introduced a clinical harm review process last year to address the backlog. It has reviewed “more than 5,000 patients”, out of the 34,938 cases to date, according to Chief Operating Officer Shaun Stacey.
    He said the trust had initially identified 83 patients who could have come to “potential harm”.
    Read full story
    Source: HSJ, 28 January 2020
  15. Patient Safety Learning
    In a report published today, AvMA, the charity Action Against Medical Accidents, reveals serious delays in NHS trusts implementing patient safety alerts, which are one of the main ways in which the NHS seeks to prevent known patient safety risks harming or killing patients.
    The report, authored by Dr David Cousins, former head of safe medication practice at the National Patient Safety Agency, NHS England and NHS Improvement, identifies serious problems with the system of issuing patient safety alerts and monitoring compliance with them. Compliance with alerts issued under the now abolished National Patient Safety Agency and NHS England are no longer monitored – even though patient safety incidents continue to be reported to the NHS National Reporting and Learning System.
    David said: “The NHS is losing it memory concerning preventable harms to patients. Important known risks to patient safety are being ignored by the NHS. The National Reporting and Learning System, the NHS Strategy and new format patient safety alerts, all managed by NHS Improvement, now ignore the majority of ‘known/wicked harms’ which have been the subject of patient safety alerts in the past and have now been archived."
    “Implementation of guidance in new Patient Safety Alerts can be delayed, for years in some cases. The Care Quality Commission that inspects NHS provider organisations also no longer appear to check that safeguards to major risks, recommended in patient safety alerts, have been implemented, or continue to be implemented, as part of their NHS inspections.
    Read full story
     
    Source: AvMA, 28 January 2020
  16. Patient Safety Learning
    A national strategy is needed to tackle health risks linked to antipsychotic drugs because current policy is letting tens of thousands of people fall through the gaps, commissioners in London are warning.
    Commissioners and clinicians in City and Hackney found more than 1,000 patients in their area who were on these drugs without having regular medication reviews or health checks. They warned that, if their findings applied across England, 100,000 patients could be in the same position. 
    Although NHS England funds GP practices to carry out regular health checks on patients who are on the serious mental illness register, this excludes patients who are prescribed antipsychotics without having an SMI diagnosis — which typically covers psychoses, schizophrenia or bipolar active disorder. 
    An audit by City and Hackney Clinical Commissioning Group, carried out in July 2019 and shared with HSJ, found 1,200 patients in the area were taking antipsychotics but did not have a formal SMI diagnosis.
    The audit found most of these patients were not receiving regular health checks and a significant number may have benefited from having their medication reduced. 
    Read full story (paywalled)
    Source: HSJ, 27 January 2020
  17. Patient Safety Learning
    A surgeon has been accused of carrying out “unnecessary” shoulder operations on several NHS patients at a private hospital linked to the Ian Paterson scandal, with 217 patients recalled.
    HSJ has been told at least five patients, all commissioned by the NHS, have instructed solicitors to take legal action against Habib Rahman, a consultant orthopaedic surgeon at Spire Parkway Hospital in Solihull.
    Mr Rahman is accused of undertaking “unnecessary or inappropriate surgical procedures at Spire Healthcare hospitals” . Spire has confirmed it has recalled 217 patients over the concerns.
    The allegations come weeks before the findings are due from an independent inquiry into disgraced surgeon Ian Paterson – who was found guilty of wounding with intent after giving hundreds of patients unnecessary breast surgeries in Spire hospitals across the Midlands.
    Read full story (paywalled)
    Source: HSJ, 24 January 2020
  18. Patient Safety Learning
    The failure to pass a damning report about a scandal-hit hospital trust to the care watchdog has been criticised by the man who led the inquiry into baby deaths at Morecambe Bay.
    On Friday, a coroner ruled that the death of baby Harry Richford in 2017 resulted from neglect in the maternity unit of East Kent Hospitals NHS Trust.
    A report by the Royal College of Obstetrics and Gynaecologists (RCOG) completed a year earlier had warned of issues that contributed to Harry’s death, including senior doctors not showing up for their shifts. However, the report was never passed on to the Care Quality Commission (CQC), despite the recommendation of the Morecambe Bay inquiry in 2015 that relevant external reviews should be passed on to the watchdog.
    Bill Kirkup, who chaired the inquiry into deaths of mothers and babies at Furness General Hospital in Barrow-in-Furness, told The Independent: “When there is sufficient concern about a service to prompt an external review, the report must be available immediately to those responsible for assuring the quality of the service. That was the reason for the recommendation of the Morecambe Bay investigation, and it is disappointing that the Care Quality Commission apparently had no sight of this report until now.”
    Read full story
    Source: 26 January 2020
  19. Patient Safety Learning
    Women in labour are being denied epidurals by NHS hospitals, amid concern that a “cult of natural childbirth” is leaving rising numbers in agony.
    Last night, Matt Hancock, the Health Secretary, promised an investigation, and action to ensure women’s choices were respected, pledging to make the NHS maternity services the world-leader.
    An investigation by The Sunday Telegraph found hospitals refusing clear requests from mothers-to-be, in breach of official guidelines from the National Institute for Health and Care Excellence (NICE).
    Mr Hancock said all expectant mothers should be able to make an informed choice, knowing their choice would be fully respected.
    “Clinical guidance clearly state that you can ask for pain relief at any time – before and during labour – and as long as it is safe to do so this should never be refused. I’m concerned by evidence that such requests are being denied for anything other than a clinical reason,” he said.
    “It's vital this guidance is being followed right across our NHS, as part of making it the best place in the world to give birth. Women being denied pain relief is wrong, and we will be investigating.”
    One mother, describing her experience at one NHS Hospital said: "It made me feel unsafe psychologically - I couldn't speak up, I couldn’t say what I wanted to say, I couldn’t advocate for myself medically because people were ignoring or belittling me. It feels that in childbirth, it’s a given that the doctor is taking their personal beliefs with them to the table, whereas in any other area of healthcare that would be unacceptable."
    Read full story
    Source: The Telegraph, 26 January 2020
  20. Patient Safety Learning
    Harry Richford's death underlines the need for the health secretary to bring back the national maternity safety training fund – and there are other issues that require urgent attention – The Independent reports. 
    Harry Richford had not even been born before the NHS failed him. An inquest has concluded he was neglected by East Kent University Hospitals Trust in yet another maternity scandal to rock the NHS. His parents and grandparents have fought a tireless campaign against a wall of obfuscation and indifference from the NHS. In their pursuit of the truth they have exposed a maternity service that did not just fail Harry, but may have failed dozens of other families.
    As with the family of baby Kate Stanton-Davies at Shrewsbury and Telford Hospitals Trust, or Joshua Titcombe at the University Hospitals of Morecambe Bay Trust, it has taken a family rather than the system to expose what was going wrong. It is known that there are about 1,000 cases a year of safety incidents in the NHS across England, including baby deaths, stillbirths and children left brain damaged by mistakes.
    Last week, the charity Baby Lifeline, joined The Independent to call on the Department of Health and Social Care (DHSC) to reinstate the axed maternity safety training fund. This small fund was used to train maternity staff across the country. Despite being shown to be effective, it was inexplicably scrapped after just one year. 
    There are other issues that also need urgent attention. The inquest into Harry’s death, which concluded on Friday, lasted for almost three weeks. Without pro bono lawyers from Advocate, Brick Court Chambers and Arnold & Porter law firm, the family would have faced an uphill struggle. At present, families are not automatically entitled to legal aid at an inquest, yet the NHS employs its own army of lawyers who attend many inquests and can overwhelm bereaved families in a legal battle they are ill-equipped to fight. Even the chief coroner, Mark Lucraft QC, has called for this inequality of legal backing to end, but the government has yet to take action.
    Read full story
    Source: The Independent, 26 January 2020
     
  21. Patient Safety Learning
    England’s poorest people get worse NHS care than its wealthiest citizens, including longer waiting for A&E treatment and worse experience of GP services, a new study has shown.
    Those from the most deprived areas have fewer hip replacements and are admitted to hospital with bed sores more often than people from the least deprived areas. With regard to emergency care, 14.3% of the most deprived had to wait more than the supposed maximum of four hours to be dealt with in A&E in 2017-18, compared with 12.8% of the wealthiest. Similarly, just 64% of the former had a good experience making a GP appointment, compared with 72% of those from the richest areas.
    Research by the Nuffield Trust and Health Foundation thinktanks found that the poorest people were less likely to recover from mental ill-health after receiving psychological therapy and be readmitted to hospital as a medical emergency soon after undergoing treatment.
    The findings sparked concern because they show that poorer people’s health risks being compounded by poorer access to NHS care.
    Read full story
    Source: The Guardian, 23 January 2020
  22. Patient Safety Learning
    England's care watchdog has carried out a no-notice inspection of an NHS trust at the centre of concerns over the possible preventable deaths of babies. The Care Quality Commission (CQC) is investigating East Kent Hospitals NHS Trust but has not yet decided whether to prosecute.
    It comes as the trust is likely to be heavily criticised at an inquest into the death of baby Harry Richford.
    On Thursday, the BBC revealed significant concerns have been raised about maternity services at the trust, and a series of preventable baby deaths may have occurred there. On Wednesday and Thursday this week, the trust's maternity services were subject to an unannounced inspection from the CQC.
    On Thursday night, East Kent Hospitals University NHS Foundation Trust said in a statement: "We are truly sorry for the death of baby Harry and our thoughts and deepest sympathies go out to Harry's family. We accept that Harry's care fell short of the standard that we expect to offer every mother giving birth in our hospital and we are fully cooperating with the CQC's investigation into Harry Richford's death."
    Read full story
    Source: BBC News, 24 January 2020
  23. Patient Safety Learning
    Scores of MPs and former ministers have urged the prime minister to tackle a backlog in NHS cancer care that threatens to lead to thousands of early deaths over the next decade.
    More than 100 MPs have written to Boris Johnson after the coronavirus lockdown caused severe disruption to cancer diagnoses and treatments. They have called on him to deliver an emergency boost to treatment capacity.
    One senior oncologist has claimed that in a worst-case scenario the effects of the pandemic could result in 30,000 excess cancer deaths over the next decade.
    Read full story (paywalled)
    Source: The Times, 22 August 2020
  24. Patient Safety Learning
    LloydsPharmacy is piloting an innovative new service that offers extra help and support to mental health patients. Funded by The National Institute for Health Research Greater Manchester Patient Safety Translational Research Centre (NIHR GM PSTRC), which is a partnership between The University of Manchester and Salford Royal, the pilot is being carried out in ten community pharmacies in Greater Manchester.
    The new service, referred to as AMPLIPHY, enables pharmacists to provide personalised support to people who have been newly prescribed a medicine for depression or anxiety, or those who have experienced a recent change to their prescription.
    The pilot programme has been funded and designed by researchers at the NIHR GM PSTRC in collaboration with LloydsPharmacy. Central to the programme is the ability for patients to lead the direction of support they receive. They set their own goals and objectives and the pharmacist supports them in these. 
    Professor Darren Ashcroft, Deputy Director of the NIHR Greater Manchester PSTRC, said: "The NIHR Greater Manchester PSTRC focuses on improving patient safety across four themes, which include Medication Safety and Mental Health. AMPLIPHY covers two of these areas and we believe it has the potential to make a difference to patients, by providing enhanced support for their care in the community."
    The pilot is set to run until April 2020 when its impact will be evaluated before a decision is made on the next steps.
    Read full story
    Source: News-Medical.net, 22 January 2020
  25. Patient Safety Learning
    An electronic health record (EHR) bug that transmits and medication order for 25 mg of a drug – not the prescribed 2.5 mg – could be the difference between life and death. And it’s that seemingly impossible reality that’s bringing more industry stakeholders to the table working to better understand EHR usability and its effects on patient safety.
    “Often times when people think about usability, they think about design and then they think about the EHR vendor,” Raj Ratwani, PhD, Director of MedStar Health Human Factors Center, said in an interview with EHRIntelligence.
    “In reality, it's a very complex space. The products that are being used by frontline clinicians are shaped by the vendor. But they are also shaped by how that product is implemented at that provider site, how it's customized, and how it’s configured. All of those things shape usability.”
    EHR usability issues are an exceptionally common issue, Ratwani reported in a recent JAMA article. About 40% EHRs reported having an issue that can potentially lead to patient harm and about 786 hospitals and 37,365 individual providers may have used EHRs with potential safety issues based on required product use reporting.
    Direct safety challenges typically come from EHR products that are sub-optimally designed, developed, or implemented. Usability issues stem from a very cluttered interface or a complex medication list. Seeing a cluttered list can lead to a clinician selecting the wrong medication.  
    A major usability issue also comes from data entry. EHR users want that process to be as clean as possible. Consistency in the way information is entered is also key, Ratwani explained.
    Ratwani also wants to ensure that certification testing is as realistic as possible.
    He compared it to when a vehicle is certified to meet certain safety standards each year. This type of mechanism does not exist when it comes to EHRs because right when the product is certified, it then gets implemented, and there is no further certification of safety done at all after the initial testing.
    “One way to do that, at least for hospitals, is to have that process be something that the Joint Commission looks to do as part of their accreditation standards,” Ratwani said.
    “They could introduce some very basic accreditation standards that promote hospitals to do some very basic safety testing.”
    Read full story
    Source: EHR Intelligence, 13 January 2020
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