“Patient safety events:” For many, the phrase conjures patient falls; wrong-patient/wrong-site/wrong-procedure events; or the unintended retention of a foreign object. These were the most frequent patient safety events resulting in death or serious injury reported to The Joint Commission in 2015.
Yet health IT is increasingly cited as a contributing factor to patient safety events. One of the most common themes involves HIT configuration and workflow, which can make it difficult to locate clinical information, contribute to input errors, or encourage unsafe workarounds. At athenahealth, our goal is to reduce or even eliminate the risk that our technology, or the use or our technology, could ever harm a patient.
At athenahealth, patient safety is a philosophy, a discipline, and resulting property of our products and services. It’s the guiding principle for the company’s patient safety clinicians, who provide education to the teams developing, designing, implementing, and educating our clients. With our colleagues in Research & Development, we identify and mitigate risk in athenahealth’s services, infuse them with patient safety-centered design principles, and cultivate a culture of safety.
As Senior Manager of Patient Safety, I helped establish athenahealth’s patient safety program five years ago and now collaborate with a team steeped in clinical risk management and safety-centered design backgrounds. Together, we perform a daily review of all potential patient safety issues that were internally discovered or reported by our clients. We forecast potential failure modes in complex processes, and we are working on a taxonomy for trending and analyzing reported patient safety issues. Every day, we support the review of reported issues coming in from our clients, or from those at the company, who identify a potential patient safety concern in our products.
To understand patient safety issues is to understand the principle of six-degrees-of-separation. We must understand what leads providers to make errors that can lead to adverse events, like overlooking a drug-drug interaction warning or adopting an unsafe workflow. Equally critical is understanding why we, as technologists, sometimes get things wrong. Under-appreciating a seemingly benign change in the code base may impact a distant but dependent functionality. Incorporating inappropriate default settings in the medication ordering process could result in over- or under-dosing.
Resolving these issues requires a collaborative, team-based approach across our Research & Development division. athena’s patient safety clinicians are frequent consultants to our Product Innovation team as they design new services for the inpatient market and continually enhance existing ones. As R&D develops new areas of clinical support, we delve into the associated risks, mitigation strategies, and design considerations based on best practice recommendations.
This year, athenahealth is making patient safety a more visible and consumable service. We believe that every employee has an important role to play in assuring the safety of our services. That’s why athenahealth is embedding patient safety into all of its employees’ education, during the on-boarding process for new hires and in a monthly seminar series offered across the organization.
This week, the patient safety clinicians staffed a Patient Safety Awareness booth in our Watertown headquarters. More than 100 athenistas took the time to submit a handwritten description of how they personally pledge to improve patient safety at the company. Their response was a welcome reassurance. athenahealth is proud to reiterate our commitment to patient safety during Patient Safety Awareness Week. But as the National Patient Safety Foundation said in this year’s Awareness Week campaign: “Every day is patient safety day.” That’s true for every one of us at athenahealth.
Submitted by Seldon Saks MD - Tuesday, March 29, 2016
I think that what you are doing is awesome. Could you PLEASE work on fixing the Medication List?