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Yael K. Heher, MD, MPH; November 2017
A resident entered orders into the EHR for a biopsy specimen of a patient's rash to be sent to pathology for evaluation. The biopsy specimen was delivered to the laboratory without a copy of the orders. Because pathology and the medicine service did not share the same EHR, the laboratory could neither view the orders nor direct the biopsy to the appropriate area for analysis without a printed copy. The next day, the resident attempted to look up the results but found none.
Journal Article > Study
Jylhä V, Bates DW, Saranto K. HIM J. 2016;45:55-63.
This analysis of incident reports found that problems with handling patient clinical information were a common source of preventable adverse events. These incidents were often due to workarounds, such as recording patient information on paper instead of within the electronic medical record.
Legislation/Regulation > Sentinel Event Alerts
Sentinel Event Alert. December 10, 2018;(60):1-8.
Although adverse events and near misses are common in health care, they are almost ubiquitously underreported. Barriers to reporting include health care provider fear of repercussions, insufficient integration of reporting systems into the electronic health record, and cultural factors. This new sentinel event alert explores how organizations can change their culture to promote reporting. It highlights bright spots: organizations that use a just culture approach to investigating errors, celebrate employees who report safety hazards, and whose leaders prioritize reporting. The Joint Commission proposes actions for all organizations to take, including developing incident reporting systems, promoting leadership buy-in, engaging in systemwide communication, and implementing transparent accountability structures. An Annual Perspective reviewed the context of the no-blame movement and the recent shift toward a framework of a just culture.