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ONC Rolls Out Patient Safety Plan

July 2, 2013
by David Raths
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HHS seeks to make it easier for clinicians to report health IT-related incidents, hazards

A patient safety plan introduced July 1 by the Office of the National Coordinator for Health IT (ONC) outlines how Health & Human Services plans to respond to calls for health IT to play a greater role in reducing medical errors. Central to the effort is the push to establish mechanisms that facilitate incident reporting among users and developers of health IT.

The HHS Health IT Patient Safety Action and Surveillance Plannotes that although health IT presents many new opportunities to improve patient care and safety, it can also create new potential hazards.For example, it notes, “poor user interface design or unclear information displays can contribute to clinician errors.Health IT can only fulfill its enormous potential to improve patient safety if the risks associated with its use are identified, if there is a coordinated effort to mitigate those risks, and if it is used to make care safer.”

ONC said it would make it easier for clinicians to report health IT-related incidents and hazards through the use of certified electronic health record technology. The plan notes that EHRs can enable providers to easily initiate reports at the time of discovery without interrupting clinical workflow and can reduce reporting burden by pre-populating and transmitting incident reports to multiple entities. ONC is pursuing a structured data capture (SDC) initiative through its Standards and Interoperability Framework to identify standards that will enable adverse event data to be extracted from EHRs.

ONC and the Centers for Medicare & Medicaid Services (CMS) will consider adopting safety-related objectives, measures, and capabilities for certified electronic health records (EHRs) through the Medicare and Medicaid EHR Incentive Programs and ONC’s standards and certification criteria.

The Agency for Healthcare Research and Quality will encourage reporting to Patient Safety Organizations (PSOs) and will develop ambulatory common formats that will enhance reporting of health IT events outside the hospital.

CMS will encourage the use of the common formats in hospital incident reporting systems, and train surveyors to identify safe and unsafe practices associated with health IT.

ONC also has posted guidance clarifying that ONC-Authorized Certification Bodies (ONC-ACBs)will be expected to verify whether safety-related capabilities work properly in live clinical settings in which they are implemented.

Finally, under a new ONC contract, the Joint Commission will be working to better detect and proactively address potential health IT-related safety issues across a variety of health care settings. More information can be found at the Health IT and Patient Safety webpage.

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