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  • Title: Guide to Reducing Unintended Consequences of Electronic Health Records
    Descriptive info: .. Skip to guide navigation.. Skip to page content.. Guide to Reducing Unintended Consequences of Electronic Health Records.. Home.. The.. is an online resource designed to help you and your organization anticipate, avoid, and address problems that can occur when implementing and using an electronic health record (.. EHR.. ).. Our purpose in developing the Guide was to provide practical, troubleshooting knowledge and resources.. The Guide was developed with all types of health care organizations in mind from large hospital systems to solo physician practices.. We anticipate that the primary users will be.. implementers such as Regional Extension Centers, chief information officers, directors of clinical informatics,.. champions or "super users," administrators, information technology specialists, and clinicians involved in the implementation of an.. Frontline.. users (such as physicians and nurses) may also find the Guide useful.. The Guide is based on the research literature, other practice-oriented guides for.. implementation and use, research by its authors, and interviews  ...   your own experience and in response to emerging research findings.. The RAND Corporation prepared the Guide for the.. Agency for Healthcare Research and Quality.. under contract HHSA290200600017I, Task Order #5.. The authors of the Guide are Spencer S.. Jones, Ross Koppel, M.. Susan Ridgely, Ted E.. Palen, Shinyi Wu, and Michael I.. Harrison.. See suggested citation format.. Note: The Guide represents the opinions of the authors and does not necessarily represent the opinions or best practice recommendations of the Agency for Healthcare Research and Quality, the United States Government, or any of the other organizations with which the authors are affiliated.. Learn more about the organizations and individuals who contributed to the development of the Guide.. Guide Navigation.. Introduction.. Avoid.. Unintended Consequences.. For Future EHR Users.. For Current EHR Users.. Understand and Identify.. Understand Unintended Consequences.. Identify Unintended Consequences.. Remediate.. Assess the Problem.. Remediate the Problem.. Track the Remediation Process.. Appendix.. Case Examples.. Glossary.. External Resources.. Acknowledgments..

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  • Title: Acknowledgments | Guide to Reducing Unintended Consequences of Electronic Health Records
    Descriptive info: Several organizations and individuals contributed to the development of this guide as members of the core research team, development sites, pilot testers, or advisors.. Core Research Organizations (and Participants).. RAND Corporation (Spencer S.. Jones, Ph.. D.. , Ross Koppel, Ph.. , M.. Susan Ridgely, J.. , and Shinyi Wu, Ph.. ).. The AHIMA Foundation (Mary Madison, M.. P.. A.. , Nadine Caputo, M.. S.. Kaiser Permanente of Colorado (Ted E.. Palen, Ph.. H.. , F.. C.. AHRQ Project Officer.. Michael I.. Harrison, Ph.. Sr.. Social Scientist, Organizations and Systems.. Center for Delivery, Organization, and Markets.. Development Sites (and Participants).. Facey Medical Foundation, Mission Hills, California (Bill Gil, M.. B.. ).. Mt.. Sinai Medical Center*, New York, New York (Joseph Kannry, M.. , and Kristen Myers).. New York City Department of Health and Mental Hygiene*, New York, New York (Amanda Parsons, M.. , and Mytri Singh).. Holy Spirit Hospital*,  ...   County Health Center, Mount Pleasant, Iowa (Stephen M.. Stewart M.. E.. M.. O.. Joint Commission Resources, Oak Brook, Illinois (Jeannell Jeannell Mansur, R.. Ph.. , Pharm.. Health Information Technologies Research Laboratory, University of Sydney, Sydney, Australia (Jon Patrick, Ph.. Advisory Group.. Robert B.. Elson, M.. Past President, Clinical Systems Design, L.. L.. William F.. Jessee, M.. President and CEO, Medical Group Management Association (MGMA) Center for Research.. H.. Stephen Lieber, C.. President and CEO, Healthcare Information and Management Systems Society (HIMSS).. David C.. Kibbe, M.. Senior Advisor, American Academy of Family Physicians (AAFP).. David A.. Kreda.. Independent Consultant.. Christine A.. Sinsky, M.. Department of Internal Medicine, Medical Associates Clinic and Health Plans.. Suggested citation format:.. S.. Jones, R.. Koppel, M.. Ridgely, T.. Palen, S.. Wu, and M.. Prepared by RAND Corporation under Contract No.. HHSA290200600017I, Task Order #5.. Agency for Healthcare Research and Quality (AHRQ).. Rockville, MD.. August, 2011..

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  • Title: Introduction | Guide to Reducing Unintended Consequences of Electronic Health Records
    Descriptive info: Introduction.. Module I: Introduction to Unintended Consequences.. EHRs.. offer many advantages, but even the most experienced implementers can face unexpected difficulties.. This module provides an overview of the kinds of issues that might arise during implementation.. Key Questions.. What are unintended consequences?.. What are common examples of unintended consequences?.. Question 1: What are unintended consequences?.. can offer many benefits to health care providers and their patients, including better quality of medical care, greater efficiencies, and improved patient safety.. However, even if these benefits are achieved, you will almost certainly face some unanticipated and undesirable consequences from implementing an.. Such consequences are often referred to as unintended consequences.. Unintended consequences can undermine provider acceptance, increase costs, sometimes lead to failed implementation, and even result in harm to patients.. However, if you learn to anticipate and identify unintended consequences, you will be in a better position to make effective decisions, clarify tradeoffs, and address problems as they arise.. Question 2: What are some examples of unintended consequences?.. Here are some examples of common unintended consequences:.. More work for clinicians.. Example: After the introduction of an.. , physicians often have to spend more time on documentation because they are required to (and facilitated to) provide more and more detailed information than with a paper chart.. While this information may be helpful, the process of entering the information may be time consuming, especially at first.. Unfavorable workflow changes.. Example: Computerized physician order entry (CPOE) automates the medication  ...   as formal documentation, thus creating two distinct and sometimes conflicting medical records.. Unfavorable changes in communication patterns and practices.. Example:.. create an "illusion of communication," (i.. e.. , a belief that simply entering an order ensures that others will see it and act upon it.. ) For example, a physician fails to speak with a nurse about administering a medication, assuming that the nurse will see the note in the.. and act upon it.. Negative user emotions.. Example: Physicians become frustrated with hard-to-use software.. Generation of new kinds of errors.. Example: Busy physicians enter data in a miscellaneous section, rather than in the intended location.. Improper placement can cause confusion, duplication, and even medical error.. Unexpected and unintended changes in institutional power structure.. IT.. , quality assurance departments, and the administration gain power by requiring physicians to comply with.. -based directives (e.. , clinical decision support alerts).. Overdependence on technology.. Example: Physicians dependent on clinical decision support may have trouble remembering standard dosages, formulary recommendations, and medication contraindications during system downtimes.. Source: Campbell, EM, Sittig DF, Ash JS, et al.. Types of Unintended Consequences Related to Computerized Provider Order Entry.. J Am Med Inform Assoc.. 2006 Sep-Oct; 13(5): 547-556.. An effective way to learn about unintended consequences is through real-world examples.. The Guide provides many additional examples annotated with lessons learned.. Read case examples.. Module II.. provides tools and information for avoiding unintended consequences during.. selection,.. implementation, and day-to-day use of the.. Read more..

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  • Title: How to Avoid Unintended Consequences | Guide to Reducing Unintended Consequences of Electronic Health Records
    Descriptive info: Avoid Unintended Consequences.. Module II: How to Avoid Unintended Consequences.. Unintended consequences are unpredictable, but much can be learned from the experiences of other.. implementers and users.. Adhering to best practices for selecting, implementing, and using your.. will help you avoid unintended consequences.. This Module is divided into two sections: the first section will be more useful to organizations that  ...   more useful to current.. users.. For Future.. Users.. There are several steps that can help reduce your risk of experiencing unintended consequences of implementing an.. Read More.. For Current.. Unintended consequences can happen at any time, even long after implementation.. This section of Module II provides information and tools on avoiding unintended consequences for organizations that have already implemented an..

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  • Title: Future EHR Users | How to Avoid Unintended Consequences | Guide to Reducing Unintended Consequences of Electronic Health Records
    Descriptive info: Future EHR Users.. Future.. Implementing an.. will dramatically change how your organization functions.. To derive the full benefits of an.. , your organization needs to be ready for these changes.. A thorough and honest assessment of your organization's readiness should take place before you choose an.. Are you ready for an.. ?.. Why do you want to implement an.. How do you select an.. ?.. How do you conduct a workflow assessment?.. What are the recommended practices for avoiding unintended consequences of.. implementation?.. Question 1: Are you ready for an.. Careful consideration must be given to the question of whether your organization is ready for an.. An.. is not a panacea on its own it cannot solve problems with workflow, efficiency, staff training, or quality.. In fact, if such problems exist, implementing an.. may just make them worse.. Case Example.. Staff Readiness for.. Implementation:.. Three independent orthopedic practices recently implemented the same.. product.. Each practice struggled with their implementation because they were unprepared in many respects to move to an.. Each of the practices identified the lack of basic computing skills among staff members as a major challenge.. Before committing to acquisition of an.. , it is wise to make a careful assessment of your organization's readiness for EHR implementation.. If the assessment points to areas where your organization lacks minimum requirements for.. implementation such as a lack of basic computer skills among the staff you can benefit by remedying these deficits before trying to implement an.. Useful Tool.. Organizational Assessment Tools:.. AHRQ.. National Resource Center for Health.. includes a number of tools that can help you assess organization's readiness for EHR implementation.. Interested users can search for such tools in.. 's.. Health.. Survey Compendium.. One useful readiness survey is the Primary Care Information Project's.. Evaluation Provider Survey.. Question 2: Why do you want to implement an.. Setting goals is a critical step in the.. implementation process.. Your organization's goals in implementing an.. should be clearly stated, and the implementation plan should include strategies for achieving the goals as well as a way to measure your progress towards them.. Setting and Achieving Goals:.. The Doctor's Office Quality Information Technology program has developed a useful document on.. goal setting.. and.. has developed.. an HIT.. Evaluation Guide.. that can help you determine whether your project is achieving its goals and producing the desired results.. Conflicting Priorities: Regulatory Compliance vs.. Clinical Workflow:.. A large community hospital recently implemented a comprehensive.. The hospital's nurses were some of the most vocal critics of the new system.. In addition to generally slow response times, the nurses felt that the.. 's admission assessment form was too cumbersome and  ...   and redesign of inefficient or unsafe processes should take place before you implement your.. Workflow Assessment:.. has developed a.. Workflow Assessment for Health.. Toolkit.. In addition, the California Healthcare Foundation provides a.. tutorial on workflow analysis and process mapping.. Redesigning Hospital Workflow:.. A two-hospital health system preparing to implement a new nursing documentation and ordering system assembled an interdisciplinary team to assess their current patient admission processes.. They determined that there was significant duplicate documentation in the nurses' workflow.. Question 5: What are the recommended practices for avoiding unintended consequences of.. implementation?.. As we've emphasized, implementing an.. is a difficult process that may disrupt your organization's work and upset some colleagues and patients.. The following is a list of implementation practices based on expert consensus that should help you avoid.. -related unintended consequences during.. implementation.. Project scope is defined, with clear, reasonable, measurable goals.. Users are well informed and engaged in the implementation.. Initial milestones should produce early "wins" that will help maintain momentum toward more difficult long-term objectives.. Plans are detailed but not overly complicated.. Multiple mechanisms for collecting feedback from users are in place.. The capacity to analyze and act on user feedback is in place.. Leaders should work to develop consensus when disagreements arise.. Use of consultants should be carefully planned with specific objectives before they are employed.. A critical mass of users must be ready for the implementation.. A plan for involving clinicians must be developed, followed, and evolved.. Metrics for success should be determined beforehand and evaluated over time.. The organization should hire and deploy staff where and when they are most needed.. Maintenance routines and an environment to support ongoing quality improvement should be established.. Source:.. Ash JS, Stavri Z, Kuperman GJ, et al.. Consensus Statement on Considerations for a Successful CPOE Implementation.. 2003; 10: 229-234.. Journeys:.. has collected a number of.. success stories from early adopters of.. Managing Expectations About How.. Implementation Will Affect Workflow:.. Clinicians at a college student health center complained that the introduction of an.. significantly increased their workload.. In particular, physicians and nurse practitioners complained that the additional time they had to spend learning to use the new system combined with the additional burden of documenting patient visits in the.. reduced their capacity to focus on delivering patient care.. For additional advice on avoiding unintended consequences and tools for monitoring.. usage, you may want to consult the next section of this module, for.. Current.. In.. Module III.. we offer tools and information to better understand and identify unintended consequences.. Much of the next module is based on a model of interactive socio-technical analysis (ISTA) developed specifically to understand unintended consequences of..

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  • Title: Current EHR Users | How to Avoid Unintended Consequences | Guide to Reducing Unintended Consequences of Electronic Health Records
    Descriptive info: Current EHR Users.. Unintended consequences are not limited to the initial implementation phase.. They can occur at any time before, during, and even long after.. Continuously monitoring the functionality and use of the.. will help you anticipate and avoid adverse unintended consequences.. Key Questions.. What are some recommended practices for avoiding unintended consequences of.. use?.. How do you monitor.. usage?.. How do you survive updates?.. Question 1: What are some recommended practices for avoiding unintended consequences of.. Unintended consequences result from complex interactions between technology and the surrounding work environment.. Even if your.. implementation was well planned and executed, some unintended consequences may emerge after the.. is being used on a day-to-day basis.. The following list of recommendations for improving.. safety should help you avoid a range of adverse unintended consequences that may occur during day-to-day.. use.. Actively involve clinicians and staff in the reassessment and ongoing quality improvement of technology solutions.. Continuously monitor for problems and address any issues as quickly as possible, particularly problems obscured by workarounds or incomplete error reporting.. Use interdisciplinary brainstorming methods for improving system quality and giving feedback to vendors.. Carefully review skipped or rejected alerts.. Require departmental or pharmacy review and sign off on orders that are created outside the usual parameters.. Provide an environment that protects staff involved in data entry from undue distractions when using the technology.. Continually reassess and enhance safety effectiveness and error-detection capability, including the use of error tracking tools and the evaluation of near-miss events.. Use manual or automated surveillance techniques to continually monitor and report errors and near misses or close calls caused by technology.. Pursue system errors and multiple causations through root cause analysis (finding the real cause of the problem and dealing with it rather than simply continuing to deal with the symptoms) or other forms of failure-mode analysis.. The Joint Commission.. Sentinel Event Alert: Safely implementing health information and converging technologies.. Dec.. 2008.. A systematic approach for identifying risks that are introduced by the.. will help you anticipate and avoid unintended consequences.. Useful tools have been developed that can help you systematically evaluate the risks associated with the use of your.. Failure Modes and Effects Analysis:.. (.. FMEA.. ) is a systematic method used to proactively evaluate health care processes and to identify and assess potential vulnerabilities.. The Department of Veterans Affairs provides a.. tutorial on how to apply the.. methodology in health care settings.. CPOE.. +.. = Fewer Medication Errors:.. Pediatric chemotherapy is very complex, involves many risks, and leaves little margin for error.. A Pediatric Oncology Department conducted a failure modes and effects analysis (FMEA) of their process for pediatric chemotherapy.. Question 2: How do you monitor.. Usage Metrics.. Metrics can help you track the functionality and usage of your.. For example, the following list of metrics was developed to monitor the use of CPOE systems.. These measures are useful as examples of what can be developed to assess and improve the usefulness of an.. The reporting and audit capabilities of.. will vary, but it may be useful to evaluate potential vendors on whether their products will allow you to track these (or other similar) usage metrics.. Percent system uptime:.. calculated as the number of minutes the.. was fully functional in a given month divided by the total number of minutes.. Planned as well as unplanned downtimes should be deducted from the numerator.. Downtimes should include any time period when systems that affect clinical use were not functioning properly.. Mean response time:.. measured  ...   how the system is being used and what functions are the most or least useful.. These surveys may also alert you to patterns of use that may be suboptimal or even dangerous.. Example User Survey:.. The New York Department of Health and Mental Hygiene and Columbia University developed a.. survey that can be used in whole or in part to assess how the.. is being used in your organization.. Auditing the Use of Copy and Paste.. Copying clinical documentation can be a time-saver for busy clinicians; however it also can pose a risk to the.. integrity.. utility.. of medical records and can even affect.. patient safety.. Organizations that allow use of the copy and paste function in their.. systems may need to audit its use in order to maintain compliance with State and Federal requirements.. Copy and Paste Toolkit:.. The American Health Information Management Association has developed a.. toolkit.. that includes resources to help health care providers develop policies related to the use of copy and paste, training materials to promote the appropriate use of copy and paste, and methods to monitor the use of copy and paste within their.. Dealing with the Persistence of Paper after.. "Going paperless" in health care is a lengthy process, and it is likely that the use of paper records and forms will persist even after you implement an.. Paper does offer some features such as flexibility and tailorability that digital mediums presently do not.. However, the persistence of paper records and paper-based information tools poses a problem when these tools are used as "shadow" medical records or are used to circumvent processes or checks that are enforced in the electronic systems.. Best practices for using paper in an.. environment are not available; however some.. research has described the reasons why paper persists in health care work environments and how paper might be used more safely and effectively.. Paper Persistence after.. The Computerized Patient Record System (CPRS) is implemented throughout Veterans Affairs Medical system.. A recent study indicated that clinicians in the.. VA.. system consistently use paper to work around the limitations of.. CPRS.. Some examples of the workarounds they identified include:.. Question 3: How do you survive updates?.. No matter which system or vendor you choose, you will regularly be required to update your.. software.. When software updates do occur, you should be aware that such updates, by design, change the functionality of your.. and therefore may also lead to unanticipated and undesirable changes in the way your.. functions or is being used.. User Frustration with Frequent.. Updates:.. A behavioral health and substance abuse facility implemented a new.. Many staff members were frustrated by the seemingly constant changes and updates to the system.. One staff member said that she struggled to keep up with the "continual upgrades and modifications" and that she feels like the "target is always changing.. " Implementation of the.. led to a decrease in staff morale, and a number of staff members left as a result.. Despite Testing, Unintended Consequences Can Still Occur:.. After a year of testing at multiple sites, a large integrated health system was ready to roll out a system-wide software update for their.. Not long after the update, users reported that physician orders to stop medications had gone missing.. The "missing" stop orders had caused some patients to receive intravenous medications longer than necessary.. In the.. next module.. Much of.. is based on a model of interactive socio-technical analysis (ISTA) developed specifically to understand unintended consequences of..

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  • Title: Understand and Identify Unintended Consequences | Guide to Reducing Unintended Consequences of Electronic Health Records
    Descriptive info: Understand and Identify Unintended Consequences.. Module III: Understand and Identify Unintended Consequences.. In the previous Module we presented information and tools for choosing, implementing and using an.. The tools and information in.. Module II.. can help you avoid unintended consequences; however, even if you use these practices, there will still probably be unintended consequences associated  ...   that will help you understand why unintended consequences occur, in order to help you prepare to identify and address them.. We provide an introduction to Interactive Socio-technical Analysis (ISTA), a framework for understanding the complex interactions that lead to unintended consequences.. We demonstrate how an Issues Log can be used to identify emergent unintended consequences..

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  • Title: Understand Unintended Consequences | Guide to Reducing Unintended Consequences of Electronic Health Records
    Descriptive info: Understand.. Why do unintended consequences occur?.. Understanding why and how unintended consequences occur will help you identify and fix your current.. -related problems and will also help you avoid future unintended consequences.. The management expert, Peter Drucker, called health care workplaces "the most complex human organization[s] ever devised.. " Interactions between these complex environments and increasingly complex.. can spawn subtle unintended consequences of.. These consequences do not result from malfunctions within the.. , but from the interactions between the EHR and the work environment or between the.. and the technical and physical infrastructure.. In this section we describe Interactive Sociotechnical Analysis.. (ISTA).. , a framework to help you understand the types of interactions that can result in unintended consequences.. ISTA.. framework has four key elements:.. (as designed), or how the developers envisioned that the.. would be used.. The work environment: The policies, priorities, hierarchies, and relationships within the organization.. The technical and physical infrastructure: Other.. , medical devices, building design and layout.. (as used): The product of interactions between the.. and the work environment and the physical and technical infrastructure.. Elements of the.. framework.. (as designed) interacts with the work environment.. can alter communication and relationships among clinicians in undesirable ways, even while the.. helps eliminate other problematic and dangerous forms of communication (such as illegible prescriptions).. Post-.. Changes in Communication:.. A survey of commercial.. physician users found that communication among clinicians, and between clinicians and their patients, benefitted from.. features such as e-mail, instant messaging, improved access to patient information, and improved access to clinical guidelines.. The survey also revealed that the introduction of an.. resulted in some new communication barriers.. (as designed) interacts with the physical or technical infrastructure.. A poor fit between an.. and other.. or the physical infrastructure is a common source of unintended consequences.. Problems involving the interface with other health.. systems can lead to poor decisions, delays, data loss, errors, unnecessary testing, and system downtimes.. "Dueling systems" can result if paper-based or legacy systems continue to be used after the implementation of an.. Features of the physical layout such as the ease with  ...   doses that exceeded typical thresholds.. To circumvent the blocks, nurses simply ordered multiple doses of the same medication in order to obtain the full dose that they desired.. -in-Use Alters Clinical Authority and Oversight:.. A hospital policy at an academic medical center required infectious disease (ID) fellows to review residents'.. orders of broad-spectrum antibiotics.. However, no restrictions on the resident's ordering privileges were implemented in the system.. In order to avoid the hassle of dealing with the.. ID.. fellows, some residents would resort to "stealth dosing," that is, waiting until the.. fellows went off duty to prescribe the restricted medications.. The physical or technical infrastructure interacts with the.. There is also a two-way interaction between the.. (as used) and the.. and physical infrastructure.. The example below highlights some of the problems that can emerge when attempting to integrate an.. with other.. systems.. System Integration Problems:.. After implementing an.. , a small hospital discovered that test results from an outside lab were not being loaded properly into the.. Lab results were being attached to the wrong patient records.. User reactions to.. features may require redesign.. Finally, sometimes actual use of the.. diverges so dramatically from the original design that it becomes necessary to reconfigure some.. features.. The next example illustrates some options for reconfiguring the system when "alert fatigue" sets in.. Responding to Alert Fatigue:.. often include decision support functionalities such as drug-drug interaction, drug-dose, drug-lab, and contraindication alerting.. Several studies have identified "alert fatigue", that is, choosing to ignore alerts, as a common condition amongst clinicians using.. with decision support.. next section of Module III.. , we provide information and tools that can help you detect unintended consequences as they emerge.. We outline how to develop and maintain an "Issues Log," a central repository of.. -related problems.. Other Resources for Understanding Unintended Consequences:.. Several other researchers have proposed frameworks for understanding.. -related unintended consequences, Including Sittig's.. sociotechnical model for studying health information technology in complex adaptive health care systems.. , Henriksen's.. Human Factors Framework.. , Vincent's.. Framework for analyzing risk and safety in clinical medicine.. , and Carayon's.. SEIPS model..

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  • Title: Identify Unintended Consequences | Guide to Reducing Unintended Consequences of Electronic Health Records
    Descriptive info: Identifying.. How do you identify emergent unintended consequences?.. Identifying unintended consequences is the first step towards remediating them.. It is important to have the capacity to detect unintended consequences as they emerge, and not just retrospectively.. In Module II we suggested a set of.. usage metrics.. and a.. user survey.. that can be administered periodically to assess the users' experience and satisfaction with the.. These tools are designed for periodic retrospective assessment, but they are not likely to be as useful for rapid detection of emergent unintended consequences.. An "Issues Log" is a tool for identifying emergent unintended consequences.. The Log can take many forms and vary widely in its level of sophistication.. A basic Log is simply a repository for collecting information about problems related to the implementation and use of the.. The Log should not be just a repository for software glitches or malfunctions, or even a log of incidents or "near misses" (where problems with.. -disrupted patient care could have resulted in patient harm).. These items should certainly be recorded in the Log, but it should be more expansive and include reports of more subtle issues that could conceivably lead to problems in the future.. For example:.. "A physician complains that the templated clinical notes generated in the.. are bloated and virtually unreadable because they are filled with auto generated text and text copied and pasted from other sources".. OR.. "Nurses report that since installation of the.. they have less opportunity to talk with physicians about how patients are responding to medications.. ".. Capturing issues like these that could potentially be hazardous will help address them at an early stage.. before.. they become serious problems.. There are a several considerations involved in creating and maintaining an Issues  ...   More reports are better than fewer reports.. You can always reject a frivolous report, but you can't act on a report you've never received.. Collect all issues, problems, and unexpected situations from all sources.. All problems even problems that are clearly "user errors" have consequences.. If confidentiality or anonymity will increase the number of people reporting, then be sure to offer it and strictly abide by your offer.. How is information collected for the log?.. This depends on the size and resources of your organization.. In smaller organizations the most effective means to collect reports may be through face-to-face conversations or an anonymous suggestion box.. Larger organizations may have the resources to support a dedicated help desk or an anonymous web-based reporting system.. What information is collected in the log?.. The Issues Log should include a detailed description of the issue as well as information about potential risks that the issue poses or incidents that have occurred as a result of the issue.. The Issues Log can also include information about the issue and corrective actions that should be taken.. Issues Log Template:.. The Issues Log is a central repository of information about.. This.. Excel workbook.. serves a basic example of what an Issues Log might look like.. Your organization may wish more or less functionality (for example, the ability to query, or allow users to submit issues via the web).. This template should be adapted and modified to meet the needs of your organization.. This module sought to deepen your understanding of unintended consequences and the complex interactions that cause them.. will build on your understanding of unintended consequences and provide you with more information that can help you identify root causes and remediate unintended consequences in your organization..

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  • Title: Remediate Unintended Consequences | Guide to Reducing Unintended Consequences of Electronic Health Records
    Descriptive info: Remediate Unintended Consequences.. Module IV: Remediate Unintended Consequences.. Module III provided tools and information to help you understand and identify unintended consequences.. In this Module we provide you with tools and information that will help you pinpoint the specific causes of your.. -related problems and that will help you remediate them..  ...   the underlying causes of the most difficult-to-diagnose.. Prioritization and planning are necessary for effectively remediating your current.. -related problems; extra care should be taken to ensure that corrective actions do not lead to other adverse unintended consequences.. Monitoring the progress of your remediation plan will help ensure that you successfully resolve your..

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  • Title: Assess the Problem | Guide to Reducing Unintended Consequences of Electronic Health Records
    Descriptive info: A systematic approach will help you pinpoint the underlying causes of the most difficult-to-diagnose.. Question: How do you pinpoint the causes of unintended consequences?.. In some cases the Issues Log may contain all the information you need to identify the root causes of your.. For example, problems that stem from software malfunctions are likely to be diagnosable based on the information collected in the Issues Log.. However, issues that arise from interactions between the.. and other components of the work environment or infrastructure will likely require further investigation.. Pinpointing the Causes of Difficult-to-Diagnose Problems.. Below we outline several steps that you can take to identify the root causes of.. -related problems that result from interactions between the.. and other components of the work environment and infrastructure.. The process outlined below relies on the.. framework described in.. , and uses the first issue reported in the.. sample Issues Log.. as a case in point.. Step 1 Define the problem:.. This should be a fairly concise description of the problem.. The description captured in the Issues Log should provide sufficient information to define the problem.. For example the first issue (ID=1) in the sample Issues Log reads:.. "CPOE calculated incorrect heparin dose.. Dosing error was not identified and patient received an overdose of heparin".. Step 2 Gather evidence:.. The Issues Log should contain valuable information about the problem (for example, when and where it occurred, and the potential causes and impacts of the problem.. ) The evidence collected in the Issues Log will help you formulate hypotheses about why the problem occurred.. In the case of the heparin overdose, the Issues Log indicates the date and time when the event took place and notes that the problem was associated with clinicians working with the computerized physician order entry (CPOE) module of the.. Additionally,.. ask those who were directly involved in the incident or those who have knowledge of the problem to describe what happened.. Ask probing questions and follow up with more specific questions to ensure that you are able to focus on the root causes of the problem, rather than just the symptoms.. The questions you ask will vary with the context and characteristics of the problem you are facing.. Below is a "starter set" of questions that can help you formulate questions to identify the root causes of your.. Identify Root Causes:.. This document contains a list of questions.. that you can use or adapt to identify the root causes of your.. In addition,.. has made information and tools related to conducting root cause analyses available through its.. patient safety network.. Step 3 Construct a timeline:.. Your efforts to gather evidence should yield an extensive list of potential causes.. For problems that resulted from a series of events that occurred over time it may be helpful to construct a timeline.. (For other types of problems, a cause and effect diagram might be more useful).. Carrying forward the example of the heparin overdose in the.. ED.. , several potential causes emerged after a review of the Issues Log and interviews with those involved in the incident.. Figure 4.. 1 presents a timeline of events that led up to the adverse event that resulted from the error in the.. entry.. 1.. Timeline of events that led to the heparin overdose in the.. (Click image to enlarge).. The timeline makes it possible to construct the chain of events that led to the adverse event.. In this case a patient arrived at the.. with a suspected deep venous thrombosis (DVT).. During triage, the nurse entered an incorrect weight into the.. The physician did not notice the erroneous  ...   the incident yielded several other potential causes of the adverse event:.. patient volumes have significantly increased; physicians and nurses often feel overwhelmed.. Computerized order entry increases workload.. Physicians were not mandated to use the order entry module.. Paper-based order forms were still available in the.. Physicians often had non-prescribers (nurses and clerks) enter orders.. There was no policy or procedure that would ensure independent double checks on high risk medications.. Workstations were located in busy areas, where distractions were more likely to occur.. All of the potential causes identified for the example case have been added to the cause and effect diagram displayed below.. Each of the suspected causes has been assigned to one of the.. interaction types.. 3.. Example of a completed.. In this case it appears that.. in the.. created new work for an already busy.. physician.. The physician's response was to exploit the lack of an appropriate organizational policy and find a way to work around the system (i.. , shift the order entry burden off to the nurses.. ) This workaround, combined with the nurse's overdependence on technology, made it possible for a relatively simple data entry error to be amplified into a serious adverse event.. Step 5 Develop causal statements:.. The next step is to further refine the list of potential root causes illustrated on the cause and effect diagram.. Developing a set of clear and concise causal statements will help you focus on the systemic vulnerabilities that led to the problem, and therefore help you design more targeted approaches to eliminating and managing similar problems in the future.. The National Center for Patient Safety (U.. Department of Veterans Affairs) recommends five rules for developing usable causal statements:.. Clearly show the cause and effect relationship.. If you eliminate the root cause or contributing factor you will reduce the likelihood of similar problems occurring in the future.. Use specific and accurate descriptors for what occurred, rather than negative and vague words.. Avoid words with non-specific negative connotations or that assign blame (e.. , careless, poor, sloppy, etc.. Identify the preceding cause(s), not the human error.. Focus on systemic vulnerabilities, not human error.. Identify the preceding cause(s) of procedure violations.. Focus on the root causes, not the symptoms.. Failure to act is only causal when there is a pre-existing duty to act.. In some cases the absence of policies and procedures is the root cause.. Based on the potential causes and contributing factors shown in Figure 4.. 3, we developed three causal statements for the heparin case.. Causal Statement 1:.. High patient volumes and distractions in the Emergency Department increase the likelihood of data entry errors.. In this case an erroneous weight was entered into the.. The erroneous weight led to a miscalculation of the heparin infusion, which caused major bleeding.. Causal Statement 2:.. Some.. physicians feel that.. is slow and prefer to use paper prescription order forms.. In this case a physician chose to use a paper order form and gave it to a nurse to enter into the.. The nurse entered the order and the.. system recommended an inappropriate dose.. The nurse did not recognize the error and initiated the heparin infusion, which caused major bleeding.. Causal Statement 3:.. Lack of a policy mandating independent double checks of high-risk medications increases the chance for error.. In this case, a single nurse did not detect a dosing error and administered an excessive dose of heparin, which caused major bleeding.. The causal statements should enable you to clearly articulate one or more root causes of your.. next section of Module IV.. focuses on how to develop a plan for remediating..

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