F.15 Clinical safety risks Flashcards
What is the potential impact of introducing health information technology (IT) in healthcare?
It has the potential to improve care but also introduces unintended consequences and new challenges.
What is clinical safety?
The absence of risks, errors, and harm that occur to patients during the provision of health care.
How are ‘clinical safety’ and ‘patient safety’ treated in this context?
They are treated as synonymous.
What are the top patient safety concerns from 2013 to 2021 according to ECRI?
Alarm hazards, patient/data mismatches in EHRs, interoperability failures, caregiver distractions, data integrity failures, test result reporting errors, mislabelled specimens, and more.
Who is often attributed with the phrase ‘first, do no harm’?
Hippocrates.
What are some documented clinical safety risks associated with health IT according to AHRQ?
- Usability issues
- Mismatches between user workflow and clinical workflow
- Data entry errors
- Lack of clarity regarding information sources
- Alert fatigue
- Altered communication patterns
- Patient misidentification
What did Magrabi et al. find in their analysis of reported incidents involving IT by Australian GPs?
- 39 had an observable impact on care
- 24 were near misses
- 15 were associated with potentially hazardous circumstances
- 6 involved potential for patient harm
- 6 had no noticeable consequences
What are some examples of unintended consequences from the use of health IT?
- More work for clinicians
- Unfavourable workflow changes
- Never-ending demands for system changes
- Conflicts between electronic and paper-based systems
- Changes in communication patterns
- Negative user emotions
- Generation of new kinds of errors
- Changes in institutional power structures
- Overdependence on technology
What is the role of the Australian Commission on Safety and Quality in Health Care (ACSQHC) regarding e-Health safety?
To optimize safety and quality in the rollouts of digital clinical systems.
What are the components of the guidance produced by ACSQHC for health IT safety?
- National Guidelines for On-Screen Presentation of Discharge Summaries
- Electronic Medication Management Systems
- National guidelines for display of medicines information
- Safety Issues at Transitions of Care
- National Safety and Quality Digital Mental Health Standards
What does AIDH’s professional practice guidelines aim to ensure?
- Identification of potential hazards
- Quick identification of hazardous situations
- Systemic improvement of safety in health and e-health industries
What is one requirement for patient safety risk assessment according to AIDH guidelines?
Establish risk management.
Fill in the blank: The phrase ‘first, do no harm’ is often translated in Latin as _______.
[primum non nocere]
True or False: Most studies on health IT issues focus on effects rather than causes.
False.
What is one of the specific requirements for assessing safety risks in e-health systems?
Use appropriate methodology for risk assessment.
What are risk appetites and risk tolerances based on?
Sustainable good practice
They cater for and are consistent with specific clinical information system initiatives.
What should health informaticians articulate in relation to e-health systems?
Their risk tolerances
This allows for the assessment of whether a state of patient safety exists.
What is the requirement for obtaining stakeholder input?
Consult and communicate broadly
This is essential for establishing contexts for assessing risks associated with e-health systems.
What should health informaticians ensure about risk assessments?
They are sufficiently comprehensive
This should be based on effective stakeholder engagement.
What should be established for identified patient safety risks?
A risk mitigation plan
This is for any identified risk assessed as being above the designated risk tolerance level.
What should risk owners do regarding their allocated risks?
Accept ownership
Every identified risk should be allocated to a risk owner.
What type of register should health informaticians maintain?
A register of patient safety risks
This should relate to e-health systems and applications and accord with good practice in risk management.
What boundaries should be disclosed prior to the exchange of ownership of e-health systems?
The boundaries of risk controls
This is important to inform other stakeholders.
What should supplier organisations disclose about e-health systems?
Residual risks
This should occur prior to any exchange of ownership or right of use.
