Presentations text content in HIT Hazard Manager:
Slide1
HIT Hazard Manager: for Proactive Hazard Control
James Walker
MD, Principal Investigator, Geisinger Health System
Andrea
Hassol MSPH,
Project Director,
Abt
Associates
September 10,
2012
AHRQ
Contract
: HHSA290200600011i
,#
14
Slide2Accident Analysis
“
Most reporting systems concentrate on analyzing adverse events; this means that
injury has already occurred before any learning takes place.
”
DeRosier
, et al. (2002)
Using Health Care Failure Mode and Effect Analysis.
JC Journal on Quality Improvement.
28(5):248-269.
Slide3Patient
Harm
Analysis
(e.g., RCA)
Accident Analysis
Slide4Near-Miss Analysis
“
Most reporting systems concentrate on analyzing adverse events; this means that injury has already occurred before any learning takes place.
More progressive systems also concentrate on analyzing
close calls
, which affords the opportunity to learn from an event that did not result in a tragic outcome.
”
DeRosier
, et al. (2002)
Using Health Care Failure Mode and Effect Analysis.
JC Journal on Quality Improvement.
28(5):248-269.
Slide5Patient
Harm
Near Miss
Analysis
(e.g., RCA)
Near-Miss Analysis
Slide6Proactive Hazard Control
“
Most reporting systems concentrate on analyzing adverse events; this means that injury has already occurred before any learning takes place. More progressive systems also concentrate on analyzing close calls, which affords the opportunity to learn from an event that did not result in a tragic outcome.
Systems also exist that permit
proactive evaluation of vulnerabilities before close calls occur.
”
DeRosier
, et al. (2002)
Using Health Care Failure Mode and Effect Analysis.
JC Journal on Quality Improvement.
28(5):248-269.
Slide7”Un-Forced”
HIT-Use Error
Error in
D
esign or Implementation
Interaction between HIT and other healthcare systems
Proactive Hazard Control
Care-Process
Compromise?
Identifiable Patient
Harm?
Patient
Harm
No Adverse Effect
Near Miss
Hazard
in
Production
No
Adverse Effect
Yes
Yes
HIT-Related Hazards
Yes
Yes
No
No
No
No
Use-Error Trap
Hazard Identified?
Hazard
Resolved?
HIT-Use-Error
Trap
Slide8Proactive Hazard Control: A Case
Pre-implementation Analysis: New
CPOE
cannot interface safely with
the existing
best
-in
-
c
lass pharmacy system.
Replace
the pharmacy system with
the one that is integrated with the CPOE: Expensive 9
-month
delay
Years later, David
Classen
studied 62 HER implementations and concluded that
CPOE and pharmacy systems from different vendors can never be safely
interfaced.
Slide9The Hazard Ontology
Why
a standard language (ontology) for HIT hazards?
To decrease the cost and increase the effectiveness of hazard control.
Example:
Much of the budget of the Aviation
Safety Information Analysis and Sharing (ASIAS) system
is devoted to normalizing data—because
every airline uses
a different ontology and can’t afford to change.
Slide10Health It Hazard Manager – AHRQ ACTION Task Order
Design & Alpha-Test (266 hazards)
Geisinger
Beta-Test (Website)
Geisinger
Abt
Associates
ECRI PSO
Beta-Test Evaluation
Abt
Associates
Geisinger
Slide11Hazard Manager Beta-Test
7
sites
: integrated delivery systems, large and small hospitals, urban and rural
Usability (individual interviews)
Inter-rater Scenario Testing (individual web or in-person sessions)
Ontology of hazard attributes (group conference)
Usefulness (group conference)
Automated Reports (group conference)
4 vendors offered critiques
All-Project meeting: 6 test sites, 4 vendors, AHRQ, ONC,
FDA
Slide12HIT Hazard Manager 2.0
Demo
Slide13Slide14Hazard Ontology
Discovery:
when and how the hazard was discovered;
stage of discovery
Causation:
usability, data quality,
decision support, vendor factors, local implementation, other
organizational factors
Impact:
risk and impact of care process compromise; seriousness of patient harm
Hazard Control:
control steps; who will approve and implement the control plan
Slide15Slide16Slide17Slide18Slide19Slide20Slide21Slide22Beta-Test Analytic Methods
Content analysis of
495 Short Hazard Descriptions
Frequencies of hazard ontology factors: combinations often selected together; factors never selected
Inter-rater differences in entries of mock hazard scenarios/vignettes
Suggestions from testers to improve ontology clarity, comprehensiveness, mutual exclusivity
Content analysis of “Other Specify”
entries
Slide23Example: Unforced User Error
Unforced User Error was the second most frequently chosen factor (79 hazards).In 55 instances, another factor was also chosen:
UsabilityData QualityCDSSoftware DesignOther Org. Factors229 12933
* Multiple selections possible
Inter-rater testing revealed differing attitudes about the role of health IT in
preventing
user errors.
Slide24Ontology Revision: “Use Error”
Use
Error was often due to the absence of protections or safeguards to prevent
errors:
Added a new factor to Decision Support:
“Missing
Recommendation
or Safeguard”
Re-defined
“Unforced User Error” as “Use Error in the absence of other factors”
Slide25Hazard Manager Benefits
Slide26Value: Care-Delivery Organizations
Prior to an upgrade, learn about hazards others have
reported.
Identify hazards that occur at the interface of two vendors’ products.
Control hazards proactively.
E
stimate the risk hazards pose
and prioritize
hazard-control
efforts.
Inform user-group interactions with vendors.
Protect confidentiality.
Slide27Value: HIT Vendors
Identify the
90% of hazards that their customers do not currently
report.
Learn which
products interact hazardously
with their own.
Prioritize hazard control efforts.
Identify
hazards early in the release
of
new versions.
Preserve confidentiality.
Slide28Value: Policy Makers
Identify and categorize common hazards that occur at the interface of
specific types of products
(e.g
., pharmacy
and order entry).
Move hazard
identification earlier in the IT lifecycle
(especially prior
to production use
).
M
onitor
the success of
hazard control in
reducing health IT hazards and
decreasing their
impact on patients.
Slide29For more information:andrea_hassol@abtassoc.com
Beta-Test Final Report
available on AHRQ
website:
healthit.ahrq.gov
/
HealthITHazardManagerFinalReport
HIT Hazard Manager:
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