CLUSTERING AND PRIORITIZING PATIENT SAFETY ISSUES DURING EHR IMPLEMENTATION AND UPGRADES IN HOSPITAL SETTINGS

Our aim was to elicit, label, and prioritize clusters of de-identified patient safety issues experienced during the implementation and upgrade installations of Electronic Health Records (EHRs) in hospitals. Conference participants included clinical personnel (physicians, nurses, pharmacists), human factors experts, patient safety experts, information technology experts from vendors and hospitals, academic experts, graduate students, and other attendees. De-identified reports of patient safety issues were shared via share4safety@gmail.com by conference and non-conference attendees before and during a 90-minute session featured at the Human Factors in Healthcare International Symposium on March 8, 2017. One submitted example of a reported patient safety issue was provided to the group. During the session, each attendee shared with a partner five concerns and identified their top concern. Subsequently, each two-person group shared with the larger group these issues, which were written by a facilitator onto sticky paper and placed on the walls. The issues were grouped using pre-defined categories and new categories were identified. Next, each participant voted for the highest priority cluster and/or individual patient safety issue using stickers. This paper reports the results of the interactive session, including the labeled and prioritized clusters and illustrative examples for each cluster. These clusters may inform reporting systems and quality improvement initiatives with health information technology where choices made during implementation and upgrades as well as design flaws with EHR technology both contribute and interact to produce potential patient safety issues.