Browse > Article
http://dx.doi.org/10.14371/QIH.2021.27.2.57

Analyzing Health Information Technology and Electronic Medical Record System-Related Patient Safety Incidents Using Data from the Korea Patient Safety Reporting and Learning System  

Cho, Dan Bi (Department of Medical Law and Bioethics, Graduate School, Yonsei University)
Lee, Yu-Ra (Department of Information Medicine, Asan Medical Center, University of Ulsan College of Medicine)
Lee, Won (Department of Nursing, Chung-Ang University)
Lee, Eu Sun (Department of Preventive Medicine, University of Ulsan College of Medicine)
Lee, Jae-Ho (Department of Information Medicine, Asan Medical Center, University of Ulsan College of Medicine)
Publication Information
Quality Improvement in Health Care / v.27, no.2, 2021 , pp. 57-72 More about this Journal
Abstract
Purpose: At present, there are a variety of serious patient safety incidents related to problems in health information technology (HIT), specifically involving electronic medical records (EMRs). This emphasizes the need for an enhanced electronic medical record system (EMRS). As such, this study analyzed both the nature of and potential to prevent incidents associated with HIT/EMRS based on data from the Korea Patient Safety Reporting and Learning System (KOPS). Methods: This study analyzed patient safety incidents submitted to KOPS between August 2016 and December 2019. HIT keywords were used to extract HIT/EMRS incidents. Each case was reviewed to confirm whether the contributing factors were related to HIT/EMRS (HIT/EMRS-related incidents) and if the incident could have been prevented (HIT/EMRS-preventable incidents). The selected reports were summarized for general clarity (e.g., incident type, and degree of harm). Results: Of the 25,515 obtained reports, 2,664 incidents (10.4%) were HIT-related, while 2,525 (9.9%) were EMRS-related. HIT/EMRS-related incidents were the third largest type of incident followed by 'fall' and 'medication incidents.' More than 80% of HIT/EMRS-related incidents were medication-related, accounting for approximately one-third of the total number of medication incidents. Approximately 10% of HIT/EMRS-related incidents resulted in patient harm, with more than 94% of these deemed as preventable; further, sentinel events were wholly preventable. Conclusion: This study provides basic data for improving EMR use/safety standards based on real-world patient safety incidents. Such improvements entail the establishment of long-term plans, research, and incident analysis, thus ensuring a safe healthcare environment for patients and healthcare providers.
Keywords
Patient safety; Health information technology; Electronic health records; Hospital incident reporting;
Citations & Related Records
연도 인용수 순위
  • Reference
1 Park YT. Current status and future directions of electronic medical record systems in hospital in Korea. Health Insurance Review & Assessment Service Policy Brief. 2017;11(2):52-61.
2 Chaudhry B, Wang J, Wu S, Maglione M, Mojica W, Roth E, et al. Systematic review: impact of health information technology on quality, efficiency, and costs of medical care. Annals of Internal Medicine. 2006;144(10):742-52.   DOI
3 Magrabi F, Liaw ST, Arachi D, Runciman W, Coiera E, Kidd MR. Identifying patient safety problems associated with information technology in general practice: an analysis of incident reports. BMJ Quality & Safety. 2016;25(11):870-80.   DOI
4 Castro GM, Buczkowski L, Hafner JM. The contribution of sociotechnical factors to health information technology-related sentinel events. The Joint Commission Journal on Quality and Patient Safety. 2016;42(2):70-6.   DOI
5 Magrabi F, Ong MS, Runciman W, Coiera E. An analysis of computer-related patient safety incidents to inform the development of a classification. Journal of the American Medical Informatics Association. 2010;17(6):663-70.   DOI
6 Holden RJ, Karsh B-T. A review of medical error reporting system design considerations and a proposed cross-level systems research framework. Human Factors. 2007;49(2):257-76.   DOI
7 Korean Law Information center. Enforcement rule of the Patient Safety Act [Internet]. Sejong, Korea: Korean Law Information center; 2021 [cited 2021 Sept 10]. Available from: https://law.go.kr/lsSc.do?section=&menuId=1&subMenuId=15&tabMenuId=81&eventGubun=060101&query=%ED%99%98%EC%9E%90%EC%95%88%EC%A0%84%EB%B2%95#undefined.
8 Palojoki S, Makela M, Lehtonen L, Saranto K. An analysis of electronic health record-related patient safety incidents. Health Informatics Journal. 2017;23(2):134-45.   DOI
9 Lee JH, Lee W, Lee YR, Lee ES, Jang SG. Reports of patient safety incidents. Ulsan, Korea: University of Ulsan; 2018.
10 Classen DC, Resar R, Griffin F, Federico F, Frankel T, Kimmel N, et al. 'Global trigger tool' shows that adverse events in hospitals may be ten times greater than previously measured. Health Affairs (Millwood). 2011;30(4):581-9.   DOI
11 Korea Patient Safety Reporting & Learning System. 2020 statistical yearbook of patient safety [Internet]. Seoul, Korea: Korea Institute for Healthcare Accreditation; 2021 [cited 2021 sept 10]. Available from: https://statistics.kops.or.kr/portal/board/stat/boardDetail.do.
12 Warm D, Edwards P. Classifying health information technology patient safety related incidents-an approach used in Wales. Applied Clinical Informatics. 2012;3(2):248-57.   DOI
13 Han HW. Current status and future of hospital information system in Korea [Internet]. Cheongju, Korea: Korea Health Industry Development Institute; 2021 [cited 2021 sept 24]. Available from: https://www.khidi.or.kr/board/view?linkId=48858596&menuId=MENU02183
14 Amato MG, Salazar A, Hickman TT, Quist AJ, Volk LA, Wright A, et al. Computerized prescriber order entry-related patient safety reports: analysis of 2522 medication errors. Journal of the American Medical Informatics Association. 2017;24(2):316-22.   DOI
15 Meeks DW, Smith MW, Taylor L, Sittig DF, Scott JM, Singh H. An analysis of electronic health record-related patient safety concerns. Journal of the American Medical Informatics Association. 2014;21(6):1053-9.   DOI
16 Roehr B. US hospital incident reporting systems do not capture most adverse events. BMJ. 2012;344:e386.   DOI
17 Ministry of Health and Welfare. The Patient Safety Act will be enforced on July 29, 2016! [Internet]. Sejong, Korea: Ministry of Health and Welfare; 2016 [cited 2021 Jul 8]. Available from: https://www.mohw.go.kr/react/al/sal0301vw.jsp?PAR_MENU_ID=04&MENU_ID=0403&page=1&CONT_SEQ=333635&SEARCHKEY=TITLE&SEARCHVALUE=%ED%99%98%EC%9E%90%EC%95%88%EC%A0%84
18 Korea Patient Safety Reporting & Learning System. Patient safety incidents caused by wrong administration of neuromuscular blocker [Internet]. Seoul, Korea: Korea Institute for Healthcare Accreditation; 2019 [cited 2021 Jul 8]. Available from: https://www.kops.or.kr/portal/aam/atent/atentAlarmCntrmsrList.do
19 Lee JH. 2020 Health informatization survey report. Sejong, Korea: Ministry of Health and Welfare, Seoul, Korea: Korea Health Information Service; 2021.
20 Buntin MB, Burke MF, Hoaglin MC, Blumenthal D. The benefits of health information technology: a review of the recent literature shows predominantly positive results. Health Affairs (Project Hope). 2011; 30 (3):464-535.   DOI
21 Bates DW, Gawande AA. Improving safety with information technology. New England Journal of Medicine. 2003;348(25):2526-60.   DOI
22 Kim MO, Coiera E, Magrabi F. Problems with health information technology and their effects on care delivery and patient outcomes: a systematic review. Journal of the American Medical Informatics Association. 2017;24(2):246-50.   DOI
23 Korea Health Information Service. EMR certification standards [Internet]. Seoul, Korea: Korea Health Information Service; 2021 [cited 2021 sept 10]. Available from: https://emrcert.mohw.go.kr/menu.es?mid=a10102010000.
24 PSO Privacy Protection Center. AHRQ common formats for surveillance-hospital version 0.3 beta: event description [Internet]. Rockville, MD: Agency for Healthcare Research and Quality; 2019 [cited 2021 sept 8]. Available from: https://www.psoppc.org/psoppc_web/publicpages/surveillancecommonformats.
25 Choudhury A, Asan O. Role of artificial intelligence in patient safety outcomes: systematic literature review. JMIR Medical Informatics. 2020;8(7):e18599.   DOI
26 Kim CH. Hallym University Medical Center, development real-time predictive AI model to identify falls and pressure ulcers [Internet]. Seoul, Korea: Cheongnyeon Uisa; 2020 [cited 2021 oct 13]. Available from: https://www.docdocdoc.co.kr/news/articleView.html?idxno=2002897.
27 Campbell EM, Sittig DF, Ash JS, Guappone KP, Dykstra RH. Types of unintended consequences related to computerized provider order entry. Journal of the American Medical Informatics Association. 2006;13(5):547-56.   DOI
28 Sittig DF, Singh H. Defining health information technology-related errors: new developments since to err is human. Archives of Internal Medicine. 2011;171(14):1281-4.   DOI
29 Magrabi F, Ong MS, Coiera E. An overview of HIT-related Errors. In: Agrawal A, editor. Safety of health IT: clinical case studies. Switzerland: Springer International Publishing; 2016, p.11-23.
30 Weiner JP, Kfuri T, Chan K, Fowles JB. "e-Iatrogenesis": the most critical unintended consequence of CPOE and other HIT. Journal of the American Medical Informatics Association. 2007;14(3):387-8.   DOI
31 Harrison MI, Koppel R, Bar-Lev S. Unintended consequences of information technologies in health care-an interactive sociotechnical analysis. Journal of the American Medical Informatics Association. 2007;14(5):542-9.   DOI
32 Magrabi F, Ong MS, Runciman W, Coiera E. Using FDA reports to inform a classification for health information technology safety problems. Journal of the American Medical Informatics Association. 2012;19(1):45-53.   DOI
33 Sittig DF, Singh H. A new sociotechnical model for studying health information technology in complex adaptive healthcare systems. Quality & Safety in Health Care. 2010;19(Suppl 3):i68-74.   DOI
34 Martin G, Ghafur S, Cingolani I, Symons J, King D, Arora S, et al. The effects and preventability of 2627 patient safety incidents related to health information technology failures: a retrospective analysis of 10 years of incident reporting in England and Wales. Lancet Digital Health. 2019;1(3):127-35.
35 Cheung KC, van der Veen W, Bouvy ML, Wensing M, van den Bemt PM, de Smet PA. Classification of medication incidents associated with information technology. Journal of the American Medical Informatics Association. 2014;21(e1):63-70.