Exploring the sociotechnical intersection of patient safety and electronic health record implementation

Do telephone call interruptions have an impact on radiology resident diagnostic accuracy?

RATIONALE AND OBJECTIVES

The purpose of this study was to measure the effect of distractions, in the form of telephone call interruptions, on radiology resident diagnostic accuracy.

MATERIALS AND METHODS

Radiology resident discrepancy reports and reading room telephone logs at an academic tertiary care pediatric hospital were collected over a 13-month period. Phone call times and durations were recorded. Major discrepancy shifts (defined as a call shift where at least one major discrepancy was discovered the following morning by the attending radiologist between the resident preliminary and attending final reports), and dictation time stamps for each discrepant preliminary dictation were also recorded. Telephone call volume and preliminary report time stamps were compared between "discrepancy shifts" and "no discrepancy shifts."

RESULTS

Each call shift spanned 14 hours, during which one radiology resident was responsible for the generation of preliminary interpretations. Review of the discrepancy log data revealed 51 major discrepancies in 41 shifts, of which 39 discrepancies had documented error details and resident preliminary report time stamps. The average number of telephone calls for the "discrepancy shifts" was slightly greater than the "no discrepancy shifts" (48.59 vs. 44.02) but was not statistically significant (P = .0575). However, there was a statistically significant increase in the average number of phone calls in the 1 hour preceding the generation of a discrepant preliminary report versus the "no discrepancy shifts" (4.23 vs. 3.24 calls, P = .027). One additional phone call during the hour preceding the generation of a discrepant preliminary report resulted in a 12% increased likelihood of a resident error (P = .017).

CONCLUSIONS

Distractions in the form of telephone call interruptions may negatively impact on-call radiology resident diagnostic accuracy. Efforts should be made to limit distractions in the reading room.

An analysis of electronic health record-related patient safety concerns

OBJECTIVE

A recent Institute of Medicine report called for attention to safety issues related to electronic health records (EHRs). We analyzed EHR-related safety concerns reported within a large, integrated healthcare system.

METHODS

The Informatics Patient Safety Office of the Veterans Health Administration (VA) maintains a non-punitive, voluntary reporting system to collect and investigate EHR-related safety concerns (ie, adverse events, potential events, and near misses). We analyzed completed investigations using an eight-dimension sociotechnical conceptual model that accounted for both technical and non-technical dimensions of safety. Using the framework analysis approach to qualitative data, we identified emergent and recurring safety concerns common to multiple reports.

RESULTS

We extracted 100 consecutive, unique, closed investigations between August 2009 and May 2013 from 344 reported incidents. Seventy-four involved unsafe technology and 25 involved unsafe use of technology. A majority (70%) involved two or more model dimensions. Most often, non-technical dimensions such as workflow, policies, and personnel interacted in a complex fashion with technical dimensions such as software/hardware, content, and user interface to produce safety concerns. Most (94%) safety concerns related to either unmet data-display needs in the EHR (ie, displayed information available to the end user failed to reduce uncertainty or led to increased potential for patient harm), software upgrades or modifications, data transmission between components of the EHR, or 'hidden dependencies' within the EHR.

DISCUSSION

EHR-related safety concerns involving both unsafe technology and unsafe use of technology persist long after 'go-live' and despite the sophisticated EHR infrastructure represented in our data source. Currently, few healthcare institutions have reporting and analysis capabilities similar to the VA.

CONCLUSIONS

Because EHR-related safety concerns have complex sociotechnical origins, institutions with long-standing as well as recent EHR implementations should build a robust infrastructure to monitor and learn from them.