health it hazard manager: design & demo james m. walker, md, facp; principal investigator,...
TRANSCRIPT
Health IT Hazard Manager: Design & DemoJames M. Walker, MD, FACP; Principal Investi gator, Geisinger Health System
Andrea Hassol, MSPH; Project Director, Abt AssociatesSeptember 19, 2011
HIT Hazard Manager
Hazard Control
Hazard analysis is accident analysis before the accident happens.
Nancy Leveson
HIT Hazard Manager version 1.0
Beta Test
1. Background and Purpose
2. Hazard Manager Demo
3. Beta Test Sites and Procedures
4. Preliminary Findings
5. Next Steps
Health It Hazard Manager
Development and Alpha-Test:
Geisinger Health System
Beta Test Website Implementation:
ECRI Patient Safety Organization; Abt Associates
Beta Test Evaluation:
Abt Associates; Geisinger Health System
No Adverse Effect ”Un-Forced”
HIT-use Error
Error in HIT design or implementation
Interaction between HIT and other healthcare systems.
Care Process Compromise?
Identifiable
Patient Harm?
Patient Harm
No Adverse Effect
”Forced” HIT- use Error
HIT-Related Hazard
Hazard Identified?
Hazard Resolved?
HIT-related
Hazard
Near Miss
Yes
Yes
No
Yes Yes
No
No
No
The Contribution of HIT-related Hazards to Patient Harm
Error in HIT design or implementation
HIT-Related Hazard Interaction between HIT and other healthcare systems.
Hazard Control
”Un-Forced”
HIT-use Error
Care Process Compromise?
Identifiable Patient Harm?
Patient Harm
No Adverse Effect Near Miss
“Hazard Identified?
“Hazard Resolved?
“Hit-related Hazard
“”Forced” HIT-use Error
“No Adverse Effect
Yes
Yes
No
No
Yes Yes
No No
Hazard Control
No Adverse Effect “”Un-Forced”
HIT-use Error
”Forced”” HIT-
use Error
Hazard Identified?
Hazard Resolved?
HIT-related
Hazard
Care Process Compromise?
IdentifiablePatient Harm?
Patient Harm
No Adverse Effect Near Miss
Error in HIT design or implementation
Interaction between HIT and other healthcare systems.
Safety incident reports
HIT-Related Hazard
YesYes
No No
No
No
Yes
Yes
Feeding Back Incident Reports into Hazard Control
Health It Hazard Manager
Levels of Access (Security)
1. Health Care Organization: can enter, view and manage its own hazards; view hazards entered by other HCOs using the same software product (deidentified as to HCO)
2. Software Vendor: can view its customers hazards (deidentified as to HCO)
3. Policymakers, Researchers, Regulators: can view all hazards (deidentified as to HCO and vendor)
Health It Hazard ManagerOntology of Hazards
• Discovery: when, how and who discovered the hazard; stage of discovery
• Causation: usability, data quality, software design, hardware, clinical decision support, implementation, user factors, other organizational factors
• Impact: risk and impact of care process compromise; seriousness of patient harm
• Corrective Action: interim and definitive fix, urgency
Percent of Hazards with Specified Attribute All Hazards My Organization’s Hazards
Faulty Recommendation 3/13 (23%) 0/4 (0%)
Missing Recommendation 1/13 (8%) 0/4 (0%)
Clinical Content Inadequate 1/13 (8%) 0/4 (0%)
Decision-Engine Logic Inadequate 1/13 (8%) 0/4 (0%)
Inappropriate Level of Automation 0/13 (0%) 0/4 (0%)
Other (specify) 1/13 (8%) 0/4 (0%)
Health It Hazard Manager
Beta Test
–
version
1.0
7 test sites: integrated delivery systems, large and small hospitals, urban and rural
– Usability
– Usefulness
– Ontology of hazard attributes
– Automated Reports
– Inter-rater Reliability
4 vendors
Beta Test Preliminary Findings
• An individual’s role determines what hazards they become aware of:- IT Implementation teams learn
about potential hazards during testing
- IT Production teams learn about hazards that may compromise care processes
- Patient Safety teams learn about care process compromises that reach patients (with or without harm)
• Hospitals have separate IT issues and patient inc ident reporting systems
- are not explicitly designed for hazard identification
- but can help teams identify hazards
Beta Test Preliminary Findings
• Failures to control hazards are often labeled “User Error”. The Hazard Manager supports more hazard control and less “blame the user”.
• “Harm” is often limited to physical injury. The Hazard Manager raises awareness about psychological, financial and reputational harm.
• Each causation category includes an “other specify” option to elicit additional user insights; the ontology will evolve over time to capture additional attributes of Health IT hazards.
Project Schedule
• Beta Test data collection complete, October, 2011• Data analysis, November - December 2011• All sites project meeting, December 2011• Final Report, May 2012• Software revised, May 2012
Questions? Comments?
For more information: