2019-08-01

Medical Error - How big is the problem?

We approach the 10 year anniversary of publication of the Institute of Medicine's report, "To Err is Human: Building a Safer Health System," with growing awareness that health information systems can both prevent and contribute to medical error.

Where Safety relates to freedom from unacceptable risk, eSafety relates to freedom from unacceptable risk associated with the development, implementation and use of health information systems.

There have been great advances in our understanding of health safety, with many Canadian Patient Safety Institute facilitated initiatives now protective in health care facilities. We are also more measured in our understanding of patient safety, even recognizing that we may have over-estimated some risks. A recent healthydebate article explores the thinking.

What is Connect Care doing about patient safety and eSafety?

  • eSafety Framework
    • Clinical System Design (CSD) is informed by an eSafety Framework developed and adopted at the beginning of Connect Care. 
  • User Interface Review
    • Emerging clinical content is tested against an eSafety Checklist to avoid known interface and informational risks. Experienced human factors specialists facilitate this work.
  • Workflow Review
    • Human Factors also facilitates a detailed, click-by-click, review of common and complex workflows to ensure that no new interface, information or interaction flaws increase risks.
  • Safety Incident Reporting
    • The AHS safety reporting system is integrated with Connect Care, enabling users to report near-misses and other events without breaking workflows.
  • eSafety Tracking
    • Safety incident reporting and tracking now includes specific characterizations for errors directly or indirectly related to information system use.
  • Embedded Problem Reporting
    • Users are able to report, from within Connect Care information flows, aspects of their Connect Care experience that might contribute to error or safety.
We'll share more specifics as clinicians make their way through training and enhance our eSafety vigilance.

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