HIM 200 Module 5 Usability and Safety Short Paper Example

The Right Note in the Wrong Chart: Usability, Safety and Record Integrity at Brennan County

[Student Name]

Southern New Hampshire University

HIM 200: Introduction to Health Information Technology

Module Five Short Paper

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

The Right Note in the Wrong Chart: Usability, Safety and Record Integrity at Brennan County

Electronic records were supposed to eliminate illegible handwriting and misfiled pages, and they largely have. But they introduced new kinds of errors. At Brennan County Medical Center, the HIM department corrects about 38 entries a month that were documented in the wrong patient's chart. This paper describes three recent near misses, explains them with research on usability and safety and proposes safeguards that HIM can lead.

Near Miss One: The Wrong Chart

A nurse caring for two patients with the same last name had both charts open and documented a blood glucose reading and an insulin dose in the wrong one. The error was caught at the next shift when the second patient's glucose trend made no sense. No insulin was given in error, but the misplaced entry could have led to a wrong dose. HIM corrected the record through the amendment process, moving the entries and preserving an audit trail of the change.

Near Miss Two: The Copied Medication List

A hospitalist's progress note, copied forward from the previous day, listed an anticoagulant that had been stopped because of bleeding. A covering physician reading the note at night assumed the drug was still active and nearly reordered it. The pharmacist caught the discrepancy. The note itself was accurate on the day it was first written; the danger came from carrying it forward without updating it.

Near Miss Three: The Buried Result

An emergency department chest scan showed an incidental lung nodule needing follow-up. The finding appeared in the radiology report, but the results screen displayed only the first lines of each report, and the nodule was mentioned in the final paragraph. The patient was discharged without being told. A quality review found the omission four months later, and the patient was called back. The follow-up scan was benign, but the delay could have mattered. The radiologist had done everything right; the problem was that the screen clinicians used every day showed too little of what the radiologist wrote.

An Old Warning

Ash et al. (2004) showed that the very systems bought to stop mistakes can open new paths to them. They identified problems in entering and retrieving information, such as interfaces not suited to busy, interrupted work, and in coordinating care, where software may expect tasks to unfold in tidy sequence when real clinical work loops back and overlaps. Each of Brennan County's near misses fits their categories: two involve retrieval and display, one involves entry in a crowded, interrupted setting.

Order Entry Can Introduce Risk

Koppel et al. (2005) studied a hospital's computerized order entry system through interviews, observation and surveys and identified 22 types of medication error risks the system facilitated, including fragmented displays that made it hard to see all of a patient's medications and failures to discontinue drugs when new orders were entered. The copied-forward anticoagulant resembles those problems: the record held accurate information, but the way it was displayed and reused hid the most important fact.

Design and Setup Both Matter

Ratwani et al. (2018) asked emergency physicians at four health systems using two major record products to complete the same clinical tasks. They found up to ninefold differences in time and eightfold differences in clicks for the same task, and error rates as high as 50% for a medication taper. Differences appeared even between sites using the same vendor, showing that how a hospital configures its system matters as much as the product. Brennan County's truncated results display is a local configuration choice, not a vendor requirement.

How Often Usability Contributes to Harm

Howe et al. (2018) analyzed about 1.7 million patient safety event reports from three health systems. Nearly 2,000 explicitly mentioned a record product and were likely related to usability, and more than 550 described events that may have harmed patients. The researchers noted that safety reports undercount problems, so the true numbers are likely higher. At Brennan County, only one of the three near misses was formally reported; the others surfaced by chance.

Copy and Paste

Tsou et al. (2017) reviewed safety events, expert opinion and literature on copy and paste and concluded that the practice can support efficiency but also introduces outdated or incorrect information and makes notes harder to read. They recommended that organizations make copied text identifiable, provide policies and training and monitor use. Brennan County has no copy-and-paste policy, and its record system can highlight copied text but that feature has never been turned on.

A Sociotechnical Explanation

Sittig and Singh's (2010) sociotechnical model helps explain why none of these near misses had a single cause. The wrong-chart entry involved the interface, which allowed two similar charts to be open, and workflow, since the nurse was interrupted. The copied note involved people, clinical content and missing policy. The buried result involved the interface and the absence of measurement, since nobody tracked follow-up of incidental findings.

What HIM Can Do

HIM is responsible for the integrity of the legal health record, which makes it a natural leader for several safeguards. Table 1 lists five that fit Brennan County's near misses.

Table 1. HIM-Led Safeguards

Note. Proposed by the author for the patient safety committee.

Measuring Improvement

Three measures would show progress: wrong-patient corrections per month, the share of audited notes with outdated copied content and the share of incidental imaging findings with documented follow-up within 30 days. HIM can report all three to the patient safety committee quarterly.

Conclusion

Brennan County's near misses show that electronic records can hide information as easily as they organize it. Research confirms these risks are common, that configuration choices shape them and that copy and paste needs rules. Because HIM safeguards the record's integrity, it is well placed to lead corrections, audits and policy, turning scattered near misses into data the hospital can use.

References

Ash, J. S., Berg, M., & Coiera, E. (2004). Some unintended consequences of information technology in health care: The nature of patient care information system-related errors. Journal of the American Medical Informatics Association, 11(2), 104-112. https://doi.org/10.1197/jamia.M1471

Howe, J. L., Adams, K. T., Hettinger, A. Z., & Ratwani, R. M. (2018). Electronic health record usability issues and potential contribution to patient harm. JAMA, 319(12), 1276-1278. https://doi.org/10.1001/jama.2018.1171

Koppel, R., Metlay, J. P., Cohen, A., Abaluck, B., Localio, A. R., Kimmel, S. E., & Strom, B. L. (2005). Role of computerized physician order entry systems in facilitating medication errors. JAMA, 293(10), 1197-1203. https://doi.org/10.1001/jama.293.10.1197

Ratwani, R. M., Savage, E., Will, A., Arnold, R., Khairat, S., Miller, K., Fairbanks, R. J., Hodgkins, M., & Hettinger, A. Z. (2018). A usability and safety analysis of electronic health records: A multi-center study. Journal of the American Medical Informatics Association, 25(9), 1197-1201. https://doi.org/10.1093/jamia/ocy088

Sittig, D. F., & Singh, H. (2010). A new sociotechnical model for studying health information technology in complex adaptive healthcare systems. Quality and Safety in Health Care, 19(Suppl. 3), i68-i74. https://doi.org/10.1136/qshc.2010.042085

Tsou, A. Y., Lehmann, C. U., Michel, J., Solomon, R., Possanza, L., & Gandhi, T. (2017). Safe practices for copy and paste in the EHR: Systematic review, recommendations, and novel model for health IT collaboration. Applied Clinical Informatics, 8(1), 12-34. https://doi.org/10.4338/ACI-2016-09-R-0150