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Pennsylvania Patient Safety Authority: Medication Errors Attributed to Health Information Technology: A Statewide Analysis of Reported Events

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Thursday, July 13, 2017, 9:00 a.m. to 10:00 a.m. PT.

The use of health information technology (HIT) has evolved over the past decade. Although the application of HIT can help improve safety and quality, if not implemented well it can have devastating consequences on patient safety. Information technology to support clinical decision making does not replace human activity but rather changes it, often in unintended or unanticipated ways. 1 Instances of misuse, often to work around technology issues, and new sources of errors after technology implementation, have been well documented. Errors can also be caused by over-reliance and trust in the proper function of technology.2 The technology can occasionally malfunction, misdirect the user, or provide incorrect information or recommendations that lead the user to change a previously correct decision or follow a pathway that leads to an error.

In 2015, a new question was added to the Pennsylvania Patient Safety Reporting System (PA-PSRS) reporting form: "Did Health IT cause or contribute to this event?" Pennsylvania Patient Safety Authority analysts had not previously explored HIT-related medication events identified by answers to this question. This session will review the analysis of HIT-related medication errors reported to the Authority, review the contributing factors mentioned in reports and provide appropriate system-based risk reduction strategies to help facilities identify and mitigate risk and minimize potential patient harm.

The Pennsylvania Patient Safety Authority invites you to participate in the "Medication Errors Attributed to Health Information Technology: A Statewide Analysis of Reported Events" webinar on Thursday, July 13, 2017 from 12:00 p.m. to 1:00 p.m.

Following this webinar, listeners should be able to:

  • List the most common types of HIT-related errors reported to the Authority that occurred during throughout the medication-use process.
  • Describe the components of an HIT system that were associated with medication errors and the contributing factors related to those components.
  • Review organization-wide risk reduction strategies to proactively address usability issues associated with HIT.

SPEAKER(S):

Matthew Grissinger, RPh, FISMP, FASCP
Director, Error Reporting Programs
Institute for Safe Medication Practices (ISMP) and
Manager, Medication Safety Analysis
Pennsylvania Patient Safety Authority

Audience:  
  • Patient Safety Officer
  • Risk Management
  • Quality Management
  • Staff Education
  • Healthcare Leadership
  • Clinical and Non-Clinical Directors
  • Nursing
  • Laboratory
  • Patient Safety
  • Human Resources
  • Pharmacy
  • Radiology
  • Other Clinical Departments
Audience/State: