IHP 315 Module 6 Technology Short Paper Example

New System, New Errors: Health IT and Patient Safety at a Community Hospital

[Student Name]

Southern New Hampshire University

IHP 315: Patient Safety Systems and Strategies

Module Six Short Paper

[Instructor Name]

[Date]

New System, New Errors: Health IT and Patient Safety at a Community Hospital

Maple Grove went live with a new electronic health record and order entry system eight months ago. Leaders expected fewer medication errors, because handwriting and transcription would disappear. Within weeks, staff began reporting new problems: a heparin order placed from the wrong list, a discharge medication list that carried forward a drug stopped days earlier and alerts so frequent that nurses clicked past them without reading. This paper examines what research says about how health information technology affects safety, applies it to the hospital's experience and recommends how leaders should manage technology-related risk.

What Technology Can Do Well

Technology can prevent real harm. Poon et al. (2010) studied a large academic hospital before and after it introduced barcode verification with an electronic medication administration record. Using direct observation of thousands of doses, they found substantial reductions in administration errors, apart from errors in timing, along with a drop in errors capable of harming patients wherever the scanners were in use. Transcription errors, in which orders are copied incorrectly onto paper records, essentially disappeared. The study showed that well-designed technology can add a defense exactly where human attention is most likely to fail.

Maple Grove's barcode system, introduced at the same time as order entry, appears to be working: nurses report catching several wrong-patient scans a week.

How Order Entry Can Facilitate Errors

Koppel et al. (2005) studied a widely used order entry system at a large teaching hospital through interviews, observation, focus groups and a survey of house staff. They identified many ways the system made medication errors more likely. Some involved information errors, such as dose options on screen that reflected pharmacy stocking units rather than clinical guidance, which physicians mistook for recommended doses. Others involved how the system fit clinical work, such as medication information scattered across several screens, making it easy to miss relevant details, and orders that failed to stop or change when intended. Many house staff reported encountering these problems regularly.

Maple Grove's experience echoes these findings. The heparin order came from a list of preset orders in which two protocols with similar names appeared next to each other, and the discharge list error came from a feature that copied active orders without flagging recently discontinued ones.

Unintended Consequences

Ash et al. (2004) drew on research in several countries to describe the unintended consequences of patient care information systems. They grouped the resulting errors into two kinds. The first arise when entering and retrieving information: interfaces that are not suited to busy, interrupted work, forms that demand too much structured data and fragmented displays that break up the picture of a patient. The second arise in communication and coordination: systems that treat clinical work as a neat, linear sequence when it is actually full of exceptions and conversations, that remove the informal checks people used to provide each other and that create a false sense that information in the system is complete. They cautioned that such problems are not simply software defects but reflect a mismatch between technology and the real nature of clinical work.

Alert fatigue on Maple Grove's units fits their description. When the system fires dozens of low-value alerts, important ones lose their meaning.

What This Means for Administrators

The research points to a clear conclusion: technology does not eliminate risk but moves it. It removes some familiar errors, such as illegible handwriting and transcription mistakes, while introducing new ones rooted in screen design, defaults and the way systems reshape communication. For administrators, the implication is that go-live is the start of safety work, not the end. The hospital needs a way to learn continuously about how the system behaves in real use, just as it learns about other hazards through reporting and analysis.

Workarounds as Warning Signs

Staff invent shortcuts whenever software and real work pull in different directions. On Maple Grove's units, some nurses print patient wristband labels in advance and keep them at the medication cart so they can scan faster, and some physicians copy yesterday's progress note forward and edit only a few lines. Administrators are tempted to treat these habits as noncompliance and respond with reminders or discipline. The research suggests a different reading: workarounds reveal where the system slows people down or asks for something that does not match reality. Each workaround should be treated as a report of a design problem. The safety committee should ask staff to describe the shortcuts they use and why, without penalty, and then decide whether the system or the process should change so the shortcut is no longer needed.

Recommendations

Maple Grove should establish a standing health IT safety committee that includes a physician, a nurse, a pharmacist, an informatics specialist and a patient safety officer, meeting every two weeks during the first year after go-live and monthly afterward. The incident reporting form should include a simple checkbox for technology involvement, so the committee can find relevant events. Order sets with look-alike names should be reviewed and renamed, and preset heparin protocols should be consolidated into one. Discharge medication reconciliation should flag drugs discontinued in the prior 72 hours. Alerts should be reviewed for override rates, with the lowest-value alerts retired and critical ones made harder to bypass. Finally, before any major system change, a small group of frontline users should test it in realistic scenarios.

Measuring Progress

The committee should track the number of reported events involving technology, the override rate for the twenty most frequent alerts, the time to fix reported design problems and the rate of discharge medication discrepancies found by pharmacy review. A rising number of technology-related reports early on should be welcomed as evidence that staff are recognizing and reporting these hazards.

Conclusion

Maple Grove's new system has prevented some errors and created others. Research shows this is typical, not a sign of failure. Treating the system as a permanent source of hazards to be monitored, rather than a finished solution, will let the hospital keep the benefits while steadily removing the new risks.

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

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

Poon, E. G., Keohane, C. A., Yoon, C. S., Ditmore, M., Bane, A., Levtzion-Korach, O., Moniz, T., Rothschild, J. M., Kachalia, A. B., Hayes, J., Churchill, W. W., Lipsitz, S., Whittemore, A. D., Bates, D. W., & Gandhi, T. K. (2010). Effect of bar-code technology on the safety of medication administration. New England Journal of Medicine, 362(18), 1698-1707. https://doi.org/10.1056/NEJMsa0907115